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Claims - Filing a Sole Proprietor/Independent Contractor Statement

Claims Division
Filing a Sole Proprietor / Independent Contractor Statement

Ruby Tate, Claims Manager
Email: [email protected]
Phoenix:
800 W Washington St, Phoenix AZ 85007 - Phone: (602) 542-4661
Tucson:
2675 East Broadway, Tucson AZ 85716 - Phone: (520) 628-5181
FAX (use for either office): (602) 542-3373

Phone List of ICA Divisions

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Filing a Sole Proprietor / Independent Contractor Statement


Click here to download form:  Sole Proprietor / Independent Contractor Statement (PDF)

This form is for use only by a sole proprietor who is working for an employer who has workers' compensation insurance as permitted by A.R.S. §23-961(P). This form is not valid until signed and dated by both the sole proprietor and insurance carrier. If you have questions concerning this form and what it can be used for, contact your workers' compensation insurance carrier or an attorney.