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Phoenix Office
800 W Washington St, Phoenix AZ 85007
(PO Box 19070, Phoenix AZ 85005-9070)
Phone: (602) 542-1839
FAX: (602) 542-1614
| FORM NAME | LAST UPDATED |
|---|---|
| Application to Self-Administer Form | 11/22/2024 |
| Initial Application for Authority to Self-Insure Form | 11/22/2024 |
| Notice of Termination of Self-Insurance Form | 11/22/2024 |
| Parent Company Guaranty Form | 11/22/2024 |
| Request for Waiver of Security Form | 11/22/2024 |
| Self-Insurance Renewal Application Form | 11/22/2024 |
| Self-Insurer Extension Request Form | 11/22/2024 |
| Self-Insurer Notice to Commission of Change Coverage Site Form | 11/22/2024 |
| Self-Provider of Medical Benefits Form | 11/22/2024 |
| Workers Compensation Liability Form | 11/22/2024 |
| Workers Compensation Guaranty Bond Form | 11/22/2024 |
| Notice of Termination of Pool Member_s Self-Insurance Form | 11/22/2024 |