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EMPLOYER’S REPORT OF INDUSTRIAL INJURY

 
COMPLETE AND SUBMIT THIS REPORT WITHIN 10 DAYS FROM NOTICE OF ACCIDENT. FATALITIES MUST BE REPORTED WITHIN 24 HOURS.

Employer must, on this form, notify his insurance carrier of every injury or disease suffered by an employee, fatal or otherwise, which is claimed to arise out of or in the course of employment. ARIZONA REVISED STATUTES 23-908 and 23-1061
  = Required Information

EMPLOYEE

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EMPLOYER

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ACCIDENT DETAILS

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Part of Body Injured List
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CAUSE OF ACCIDENT

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Nature of Injury List
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Cause of Injury List
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EMPLOYEE'S WAGE DATA

HOURS PER DAY EMPLOYEE WORKED
NUMBER OF DAYS PER WEEK USUALLY WORKED

IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY OR MONTHLY SALARY, COMPLETE ITEMS IN BELOW SECTION

DATE OF HIRE GREATER THAN ONE YEAR PRIOR TO INJURY, COMPLETE THE FOLLOWING.IF NOT, SKIP TO NEXT QUESTION.

GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEEDING INJURY
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DATE OF HIRE LESS THAN ONE YEAR, COMPLETE THE FOLLOWING. IF NOT,SKIP TO NEXT QUESTION.

IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE THROUGH DAY PRIOR TO INJURY
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COMPLETE IF EMPLOYEE RECEIVED A WAGE INCREASE IN LAST 12 MONTHS PRIOR TO INJURY

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AUTHORIZED SIGNATURE

  
( Supported formats are .pdf, .png, .jpeg, .jpg, .tiff )
NOTE TO EMPLOYER:
1. Submit one copy to the Industrial Commission within 10 days.
2. Submit one copy to your insurance carrier within 10 days.
3. Keep one copy, for not less than five (5) years, as your supplementary record of injuries required by the Federal Occupational Safety and Health Act of 1970.

* The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commission’s forms, prescribed under the Commission’s Rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number.


THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE

Form ICA 0101 - Rev 6/2019

By signing this form electronically, I certify that I am an interested party or an authorized representative of an interested party. I further certify that I am authorized to sign this form and that all of the representations included in this form are true, accurate, and complete.

I agree


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