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| Form Number | Form Name | Last Updated |
|---|---|---|
| Accounting_6601 | Insurance Carrier - Quarterly Tax Form | 01/05/2024 |
| Accounting_6604 | Insurance Carrier - Annual Tax Form 200 | 01/24/2024 |
| Accounting_6605 | Self-Insured Employer - Quarterly Tax Form | 09/18/2023 |
| Accounting_6608 | Self-Insured Employer - Annual Payroll Report Form | 01/05/2024 |
| Accounting_6609 | Self-Insured Employer - Annual Medical Report Form | 01/05/2024 |
| Accounting_6611 | Self-Insured Employer - Annual Injury Report Form | 01/05/2024 |
| Accounting_6613 | Self-Insured Employer - Annual Hospital Report Form | 01/09/2024 |
| Accounting_6618 | Reversal Form for Reversing Automated Payment Processing | 12/24/2018 |
| Accounting_6627 | State of Arizona Substitute W-9 and ACH Vendor Authorization Forms & Instructions | 09/18/2023 |
| Accounting_6628 | Self-Insurer Request for Extension to File Tax Forms | 11/22/2024 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| ADOSH_2212 | (ADOSH) INJURY - Report a Fatality or Severe Injury Form | 11/18/2024 |
| ADOSH_2213 | ADOSH - Notice of Alleged Safety or Health Hazards Form | 09/19/2024 |
| ADOSH_2215 | (ADOSH) WHISTLEBLOWER - Discrimination / Whistleblower Complaint Form | 12/09/2024 |
| ADOSH_2217 | ADOSH - CONSULTATION - Survey Request Form | 09/19/2024 |
| ADOSH_2218 | ADOSH - CONSULTATION - Training Request Form | 09/19/2024 |
| ADOSH_2224 | (ADOSH) VPP Compliance Assistance Request Form | 11/18/2024 |
| ADOSH_2225 | ARIZONA DIVISION OF OCCUPATIONAL SAFETY AND HEALTH(ADOSH) - Voluntary Protection Program(VPP) Pre-Screening Form | 11/07/2024 |
| ADOSH_2226 | ADOSH - SHARP - Recognition Application Form | 09/19/2024 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| ADOSH_2216 | (ADOSH) BOILER - Pressure Vessel Inspection Report Form | 11/18/2024 |
| ADOSH_2222 | ADOSH - BOILER - Request for Boiler Repair Form | 09/19/2024 |
| ADOSH_2223 | (ADOSH) BOILER - Boiler New Install / Reinstall Form | 11/18/2024 |
| ADOSH_2228 | (ADOSH) BOILER - New Boiler Inspector Application | 11/18/2024 |
| ADOSH_2232 | (ADOSH) BOILER - Inspector (PBI) Renewal Application | 11/18/2024 |
| ADOSH_2233 | ADOSH - BOILER - Variance Applications Forms | 10/03/2024 |
| ADOSH_2234 | ADOSH - BOILER - Alternative Clearance Forms | 10/03/2024 |
| ADOSH_2235 | ADOSH - BOILER - Accident Investigation Request Form | 09/19/2024 |
| ADOSH_2236 | ADOSH - BOILER - Inspector Complaint Forms | 09/19/2024 |
| BOILER_0001 | ADOSH - BOILER - Boiler Change of Ownership Form | 09/19/2024 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| ADOSH_2221 | (ADOSH) ELEVATOR - Application for Permit to Install or Alter Elevator Form | 11/18/2024 |
| ADOSH_2227 | (ADOSH) ELEVATOR - Private Inspector (PEI) New Application Form | 11/18/2024 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| Claims_0101 | Employer Report of Injury Form | 05/27/2022 |
| Claims_0102 | Worker’s and Physician’s Report of Injury Form | 05/27/2022 |
| Claims_0113 | Employee Rejection of Terms Form | 08/12/2016 |
| Claims_0114 | Employee Revocation of Rejection of Terms Form | 08/23/2016 |
| Claims_0120 | Dependent Benefits Claim Form | 06/07/2019 |
| Claims_0121 | Request to Change Doctors Form | 06/07/2019 |
| Claims_0122 | Request to Leave State Form | 06/07/2019 |
| Claims_0123 | Professional Employer Agreement Form | 09/16/2016 |
| Claims_0124 | Bodily Fluids Work Exposure Form | 09/16/2016 |
| Claims_0407 | Worker’s Report of Injury Form | 10/24/2024 |
| Claims_0446 | Request for Hearing Form | 06/07/2019 |
| Claims_0447 | Request for Continuance Form | 10/30/2024 |
| Claims_0448 | Request for Hearing Withdrawal Form | 10/29/2024 |
| Claims_0528 | Petition to Reopen Form | 06/07/2019 |
| Claims_0529 | Petition for Rearrangement Form | 06/07/2019 |
| Claims_110A | Annual Report of Income Form | 08/12/2016 |
| Claims_110B | Notice of Intent to Suspend Form | 08/12/2016 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| Labor_3303 | Unpaid Wage Claim Form | 10/24/2024 |
| Labor_3304 | Payment Compliance Complaint Form | 02/25/2022 |
| Labor_3305 | Earned Paid Sick Time Claim Form | 02/25/2022 |
| Labor_3306 | Youth Labor Complaint Form | 02/25/2022 |
| Labor_3307 | EPST/Minimum Wage Retaliation Claim Form | 02/25/2022 |
| Labor_3325 | Minimum Wage Claim Form | 02/25/2022 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| Legal_4401 | Public Records Request Form | 04/01/2020 |
| Legal_4402 | Uninsured Employer Complaint Form | 12/09/2024 |
| Legal_4403 | Employers Workers Compensation Insurance Inquiry Response Form | 07/12/2017 |
| Legal_4404 | Petition for Attorney’s Fees | 03/08/2018 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| MRO_7711 | Medical Treatment Preauthorization Form | 10/24/2024 |
| MRO_7712 | Informal Payment Dispute Form | 12/09/2024 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| SpecFund_5413 | Workers Supplemental Claim Form 413 | 08/12/2016 |
| SpecFund_5525 | Carrier's Notification of Scheduled Injury Time Loss | 08/12/2016 |
| SpecFund_5526 | Workers Supplemental Claim For Compensation | 01/18/2017 |
| SpecFund_5527 | Apportionment Settlement Letter | 02/01/2021 |
| SpecFund_5528 | Vocational Rehabilitation Referral | 06/07/2019 |