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Phoenix Office
800 W Washington St, Phoenix AZ 85007
(PO Box 19070, Phoenix AZ 85005-9070)
Phone: (602) 542-5795
FAX: (602) 542-1614
| FORM NAME | LAST UPDATED |
|---|---|
| Self-Insurer Notice of Change in Coverage | 10/27/2023 |
| Self-Provider of Medical Benefits | 10/27/2023 |
| Workers' Compensation Liability Form | 10/27/2023 |
| Initial Application for Authority to Self-Insure | 07/20/23 |
| New Pool Member Application | 07/20/23 |
| Notice of Termination of Self-Insurance | 07/20/23 |
| Parent Company Guaranty | 07/20/23 |
| Custody Agreement | 07/20/23 |
| Application to Self Administer | 07/20/23 |
| Notice of Termination of Pool Member's Self-Insurance | 07/20/23 |
| Statutory Deposit Agreement | 07/20/23 |
| Request for Waiver of Security | 07/20/23 |
| Workers' Compensation Guaranty Bond | 07/20/23 |
| Self-Insurance Renewal Application | 07/20/23 |