A list of the necessary forms for filing for workers’ comp claim in Arizona
According to Arizona state law, employers must carry workers’ compensation insurance for their employees. The insurance provides monetary compensation in the event that a worker suffers an injury or is fatally harmed. The benefits include temporary or permanent payments, medical care reimbursements and possible job training fees.
By visiting the website of the Industrial Commission of Arizona (ICA), injured full- or part-time employees may start the claim process by filling out and mailing the completed paperwork.
Here’s a list of 10 forms injured workers in Arizona should know about when filing a workers’ compensation claim:
Worker’s Report of Injury Form/Worker’s and Physician’s Report of Injury Form
Injured employees must file a claim using one of the Arizona workers’ compensation forms. The claim must be filed with the ICA within 12 months of the date of the injury. Filing a claim involves completing the Worker’s Report of Injury Form (0407) or the Worker’s and Physician’s Report of Injury Form (0102). Both forms require the name and address of the employer, along with the location of the accident.
When submitting Form 0102, you will need the original and 2 copies of the form. This allows you and the treating physician to include the required information. Your completed form must include the date and time indicating when the accident occurred.
The physician completes the second half of the form, then signs and dates the document. The physician must send one of the forms to the Industrial Commission of Arizona within 8 days after providing treatment. You must provide your employer with a copy as well. Lastly, a third copy must be sent to the employer’s workers’ compensation insurance company.
Employer Report of Injury Form
On the employer’s side of things, they can submit the Employer Report of Injury Form (0101) within 10 days of being notified. They must send copies to the ICA as well as their insurance company. If there has been a fatality, the employer must notify the ICA within 1 business day.
However, employers seldom file the report of injury, which is why it’s imperative the injured worker does so. Do not rely on your employer to file the report of injury form.
Request to Change Doctors Form
It’s common for workers’ compensation insurance companies to insist that injured employees be treated by a company recommended physician. But, for many different reasons, you may desire to visit a different physician. You might need a second opinion for diagnosis or disagree with the initial medical provider’s treatment. The physician may not comply with the provisions stated in A.R.S. § 23-1062.02(C)(2), which causes the insurance company or the employer to request a change.
In any case, you must complete a Request to Change Doctors Form (0121). First, however, you must ensure that the physician you desire to see is willing to provide treatment and receive payment via the workers’ compensation claim. Also, some employers can direct care which will prevent you from changing doctors.
Request for Hearing Form
When the workers’ compensation insurance company denies benefits, you may decide to appeal the case by requesting a hearing. In such cases, the Request for Hearing Form (0446) must be completed and include the reason for the hearing. The information may involve the receipt of a specific notice, award or order that you protest. Failure to provide a reason commonly results in a hearing delay.
Workers Supplemental Claim Form 413
The Workers Supplemental Claim Form 413 (5413) must be completed by an injured worker who is currently prescribed only light-duty work. The form is designed to report earnings and to calculate the benefits owed to you.
This form must be completed with a work search and reporting of earnings, and filed in order to continue receiving ongoing benefits. However, any false information provided results in a felony, which is punishable by up to 18 months in prison, a $50,000 fine and loss of compensation.
Vocational Rehabilitation Referral
In the event that you can’t return to your former occupation due to medical circumstances, you may desire to receive training in another profession. The Special Fund’s Vocational Rehabilitation program is available for assistance. But first, the Vocational Rehabilitation Referral Form (5528) must be completed by the insurance carrier, a self-insured employee or a third-party administrator (TPA) representative. The document must include pertinent medical information.
Uninsured Employer Complaint Form
In Arizona, it’s required for employers to carry workers’ compensation insurance. If you are aware that your employer (or that of a loved one) does not carry the proper insurance, you can file a complaint using the Uninsured Employer Complaint Form (4402). Provide as much information as you can when filling out this grievance.
Questions and answers about compensation for a job-related accident, injury or illness in Arizona
Consult an Arizona workers’ compensation insurance attorney
An employee who suffered an injury on the job should consider consulting with an attorney who specializes in workers’ compensation cases. A lawyer initially reviews the case and the employer’s policy before guiding a client through the process of filing for benefits.
Being awarded compensation under the law is not difficult. However, should you be denied benefits for any reason, combining efforts with an experienced and qualified attorney increases the likelihood of receiving due compensation.
