1. A. The following forms, and accompanying instruction sheets, are available at http://www.azica.gov or upon request from the Commission Claims Division, and shall be used when applicable:

   1. 1. Employer Report of Injury,
   2. 2. Worker’s and Physician’s Report of Injury,
   3. 3. Worker’s Report of Injury,
   4. 4. Dependent Benefits Claim,
   5. 5. Notice of Claim Status,
   6. 6. Carrier’s Recommended Average Monthly Wage Calculation,
   7. 7. Request to Leave the State,
   8. 8. Request to Change Doctors,
   9. 9. Request for Hearing,
   10. 10. Notice of Suspension of Benefits,
   11. 11. Notice of Permanent Disability Benefits,
   12. 12. Notice of Death Benefits,
   13. 13. Notice of Permanent Disability and Request for Determination of Benefits,
   14. 14. Notice of Supportive Medical Maintenance Benefits,
   15. 15. Petition to Reopen,
   16. 16. Petition for Rearrangement,
   17. 17. Annual Report of Income,
   18. 18. Notice of Intent to Suspend,
   19. 19. Permanent Compensation Payment Plan,
   20. 20. Compliant of Bad Faith and Unfair Claim Processing Practices,
   21. 21. Report of Significant Work Exposure to Bodily Fluids or Other Infectious Material,
   22. 22. Professional Employer Agreement,
   23. 23. Employee Rejection of Terms,
   24. 24. Employee Revocation of Rejection of Terms,
   25. 25. Administer Account Request,
   26. 26. Change, Combine or Delete Request,
   27. 27. Request to Maintain an Out-of-State Claims Office,
   28. 28. Medical Treatment Preauthorization.
2. B. Forms prescribed under subsection (A) shall not be changed, amended, or otherwise altered without the prior written approval of the Commission.

Historical Note

Former Rule 6. Amended effective March 1, 1987, filed February 26, 1987 (Supp. 87-1). Amended effective August 28, 1992 (Supp. 92-3). R20-5-106 recodified from R4-13-106 (Supp. 95-1). Amended by final rulemaking at 7 A.A.R. 3966 and 7 A.A.R. 4995, effective August 17, 2001 (Supp. 01-3). Amended by final rulemaking at 15 A.A.R. 991, effective June 2, 2009 (Supp. 09-2). Amended by final rulemaking at 24 A.A.R. 2069, effective October 1, 2018 (Supp. 18-3). Amended by final rulemaking at 31 A.A.R. 4199 (October 31, 2025), effective December 6, 2025 (Supp. 25-4).