Every state has different laws concerning worker’s compensation; in Arizona, every employer has to provide workers’ compensation insurance. You may be compensated if you get a work-related injury; however, it is a worker’s responsibility to file a claim since some employers can be ignorant.

Workers comp claim in Arizona has to be done within one year of getting the injury; otherwise, it may not be approved. Benefits from workers’ compensation claims are gained by following some procedures and filling in some forms. Below is an explanation of some of these forms.

Workers and Physician Report of Injury / Workers Report of Injury

If a work-related injury occurs, workers should make a workers’ compensation claim by filling and submitting either a Worker’s Report of Injury (0102) from the ICA or a Worker’s and Physician’s Report of injury (0407) from the doctor’s office.

Workers’ comp claims are awarded if, in both forms, the place where the accident/injury occurred, together with the address and name of the employer, has been indicated as required.

Employer Report of Injury Form


The employer submits the Employer Report of Injury Form (0101) within ten days of being aware of the incident. The employer must send copies to the insurance company and the Industrial Commission of Arizona (ICA).

The employer must inform the ICA to win one business day if a fatality occurs. In most cases, employers rarely file the report of injury form, so the injured worker must put effort into filing the report.

Request to Change Doctors Form

Most workers’ comp insurance companies recommend that a hospital recommended by company treat injured employees, but for various reasons, the employee may prefer to go to a different hospital. In such a scenario, the employee must submit a Request to Change Doctors Form (0121); however, you must confirm that the new doctor will receive payment and provide treatment with the worker’s compensation claim.

Request for Hearing Form

Workers comp claims in Arizona can be tiring since the insurance company can deny providing the benefits. In such a case, the Request for Hearing Form (0446) must be filled and submitted, indicating the reason for the hearing.

Workers Supplemental Claim Form 413


Injured employees who have been allowed light-duty work are supposed to submit the Workers Supplemental Claim Form 413 (5413), which calculates benefits owed and reports your earnings.

A word search has to be completed with the payments filed so that the benefits can continue being released.

Vocational Rehabilitation Referral Form

Vocational Rehabilitation Form (5528) is filed if you can’t resume your previous duties due to medical complications, and you might want training in another field or profession.

The form must meet requirements such as relevant medical information and be filed by a self-insured employee, third-party administrator, or insurance carrier.

Uninsured Employer Complaint Form


Since workers comp insurance is compulsory in Arizona, filing a complaint is possible using the Uninsured Employer Complaint Form (4402) if you find out that a particular employer does not have Workers’ insurance.

In such cases, an employee or any public member can fill in this form and provide as much information as possible.


Workers comp claim is an injured worker right in Arizona, and when you have the above forms, the process gets easier. Employees should fill in these forms correctly to be awarded the appropriate compensation for injuries or illnesses.