The Arizona ICA Employer’s Report of Industrial Injury (Form ICA 0101) is the form every Arizona employer must complete and send to its workers’ compensation insurance carrier and the Industrial Commission of Arizona after a worker reports a job-related injury, illness, or death. You file it within 10 days of learning about an accident, and you file it within 24 hours if a worker dies.
This single sheet starts the official paper trail for a workers’ compensation claim. If you skip it, fill it out wrong, or file it late, you can face civil penalties, a bigger fight with your carrier, and an angry employee who feels ignored. Roughly 30,000 to 40,000 new injury claims move through Arizona’s workers’ comp system each year, and many of them begin with this exact form, so getting it right matters more than most owners think.
Here is what you will learn in this guide:
- ✅ Who must file Form ICA 0101 and the exact deadlines that control it
- 📋 A line-by-line walkthrough of all 55 boxes, plus the signature block
- 👥 Three full filled-out examples using real-world injury scenarios
- 🚫 The 10 most common mistakes that delay claims or trigger penalties
- ❓ Clear answers to the field-level questions employers ask most
What the Form Is and Who Must File It
Form ICA 0101 is titled the Employer’s Report of Industrial Injury, and Arizona law makes the employer responsible for completing it. The form’s job is to notify your insurance carrier and the state of every injury or disease an employee claims arose out of or in the course of employment, whether it is fatal or minor. The current paper version carries the revision stamp Form ICA 04-0101 (Rev. 7/01), so confirm you have that version or the agency’s current online equivalent before you start.
Two statutes drive this form. Under A.R.S. § 23-908, employers must report covered injuries to their carrier and the Commission, and under A.R.S. § 23-1061, this report helps trigger the claim process. The Commission recently announced a streamlined form effective 04/21/2026 that no longer requires an Adobe E-Sign, which makes online filing faster.
If you are an employer with workers’ comp coverage, you must file. That includes corporations, small shops, restaurants, construction firms, and most businesses with even one covered employee. Self-insured employers file too, sending the report into their own claims system and to the Commission.
A quick note on fault: filing this form does not mean you admit the injury is work-related or that you owe anything. Box 31 even lets you state why you doubt a claim. Reporting is a legal duty, not a confession, and treating it that way protects you.
Before You Start: Documents and Information You Need
Gather everything before you open the form. Hunting for a policy number or wage record halfway through is how employers blow the 10-day deadline.
- Workers’ comp policy number. You need this for Box 9 so the carrier can match the claim to your account; a missing or wrong number sends the report to a dead end.
- Employee’s Social Security number and birth date. These go in Boxes 2 and 3 and let the Commission tell apart workers with similar names; without them, the file can stall.
- Employee’s full legal name and home address. Boxes 1 and 4 must match payroll records so benefit checks and mail reach the right person.
- Date, time, and location of the accident. Boxes 13, 14, and 24 anchor the claim’s timeline and decide whether the statute of limitations is met.
- Date you were notified of the injury. Box 16 starts your 10-day clock, so pin down the exact day a worker or supervisor told you.
- Job title, department, and class code. Boxes 19 through 22 tie the worker to the right payroll classification, which affects premium and benefit math.
- Wage records for the past 30 days and 12 months. Boxes 46 and 50 set the worker’s average monthly wage, which controls how much they get paid while off work.
- Medical treatment details. Boxes 29 and 30 ask whether the worker went to the ER or stayed overnight, which signals injury severity to the carrier.
- Name and address of any non-employee who caused the accident. Box 35 supports a possible subrogation claim, where your carrier recovers money from an at-fault third party.
If any piece is missing, do not wait. File with what you have and supplement later, because a late form is a worse problem than an incomplete one.
Where to Get the Form and How to Access It
You get Form ICA 0101 straight from the Industrial Commission of Arizona forms page, where the agency hosts the official PDF and the online filing option. Do not rely on a random copy a friend emailed you, because outdated versions may miss boxes the Commission now expects. Many third-party sites post the form, but the agency’s own page is the safe source.
The Commission also offers an online Employer Report of Injury tool that walks you through the same fields on screen and submits the report electronically. This is the fastest channel, and after the 04/21/2026 update it no longer forces an Adobe E-Sign step.
If you carry coverage through a private carrier, that carrier usually has its own copy of Form ICA 0101 branded for its claims unit, and submitting through the carrier still satisfies the Commission. Either way, the field numbers and labels are the same, so this guide applies whether you file on paper, through your carrier, or online.
Print or download a fresh copy for each injury. Reusing a marked-up form invites mix-ups, and the carrier needs a clean record for each separate claim.
Step-by-Step: How to Fill Out Form ICA 0101 Line by Line
The form groups its boxes into sections: Employee, Employer, Accident, Cause of Accident, Wage Data, and the Signature block. Work top to bottom and use the exact box numbers printed on the form.
Header: Recordable vs. Non-Recordable and OSHA Case Number
The top strip asks you to mark the injury as a Recordable Injury or a Non-Recordable Injury and to enter an OSHA Case # for OSHA purposes only. In plain terms, this header tells the carrier and the Commission how serious the event is under federal safety rules. To answer it, check “Recordable” if the injury involved medical treatment beyond first aid, days away from work, restricted duty, or death; otherwise check “Non-Recordable.”
For example, Diego Ramirez cut his hand on a box cutter, needed five stitches, and his employer marks the injury Recordable and writes the internal OSHA case number 2026-014. A common edge case is first aid only, such as a bandage, which is usually Non-Recordable.
A frequent mistake here is marking everything “Recordable” out of caution, which can inflate your OSHA log and skew your safety stats; the consequence is a paper record that makes your workplace look more dangerous than it is. The misconception is that this header decides whether the worker gets benefits, but it does not, because OSHA recordability and workers’ comp eligibility are separate questions.
Box 1: Employee Last Name, First, M.I.
This box asks for the injured worker’s full legal name, last name first. Write it exactly as it appears on payroll and on the worker’s Social Security card, in this order: last name, then first name, then middle initial. Use capital letters to keep it readable for clerks who key the data.
For example, Nguyen, Linh T. is how you enter a worker named Linh T. Nguyen. A common edge case is a hyphenated or two-part last name, such as Garcia-Lopez, which you keep together as the last name rather than splitting it.
A common mistake is entering a nickname or shortened name like “Mike” instead of “Michael,” which causes the Commission’s records to mismatch and can delay benefit checks. The misconception is that small name differences do not matter, but the Commission cross-references names with other state records, so an exact match keeps the file moving.
Box 2: Social Security Number
This box asks for the employee’s nine-digit Social Security number. Enter all nine digits in the standard format, such as 123-45-6789, and double-check each digit against payroll. The Commission requires this number under a Privacy Act exception so it can tell apart workers who share names and birth dates.
For example, Linh T. Nguyen has her HR manager copy 528-31-7740 directly from her I-9 record. A common edge case is a worker with only an ITIN or no SSN; in that situation you enter what you have and note the gap, then supplement once the number is available.
The most common mistake is transposing two digits, which sends the claim to the wrong file or creates a duplicate record that takes weeks to untangle. The misconception is that the SSN is optional for privacy reasons, but the Commission’s pre-1975 rules make it mandatory on these forms.
Box 3: Birth Date
This box asks for the worker’s date of birth. Write it in month, day, year order, such as 07/14/1990. Pull it from the same payroll or hiring record you used for the name and SSN so all three identifiers agree.
For example, Diego Ramirez enters his birth date as 11/02/1988. A common edge case is an employee who recently corrected their birth date with HR, in which case you use the corrected, verified date.
A common mistake is guessing the year because you cannot find the record, which creates an identity mismatch that can freeze the claim. The misconception is that birth date is just a formality, but the Commission pairs it with the SSN and name to confirm identity, so an error here can stall benefits.
Box 4: Home Address
This box asks for the worker’s home address, including number, street, city, state, and ZIP code. Enter the full mailing address where the worker actually receives mail, because the carrier and Commission send benefit notices and checks there. Confirm it with the employee if recent records might be stale.
For example, Linh T. Nguyen lists 4821 N. 35th Ave, Phoenix, AZ 85017. A common edge case is a worker who uses a P.O. Box; enter the P.O. Box if that is where they get mail, and add the physical address if the carrier needs it.
A common mistake is using an old address from a year-ago hire packet, which means benefit checks bounce back and the worker waits longer for money. The misconception is that the worker’s own claim form covers the address, but your report must stand on its own, so fill it in.
Box 5: Telephone
This box asks for the worker’s phone number. Enter a current 10-digit number with area code, such as (602) 555-0148, where the carrier’s adjuster can reach the worker. A reachable number speeds up the recorded statement and treatment authorization.
For example, Diego Ramirez provides his cell number (480) 555-0192. A common edge case is a worker with no phone, in which case you list an alternate contact or note “none on file.”
A common mistake is leaving this blank because “the carrier can email them,” which slows down claim handling when the adjuster cannot make quick contact. The misconception is that the phone number is minor, but adjusters often call within hours, so a missing number adds days.
Boxes 6 and 7: Sex and Marital Status
Box 6 asks the worker’s sex (Male or Female) and Box 7 asks marital status (Single, Married, Divorced, or Widowed). Check the single box that matches the worker’s records for each. These fields help the Commission assess dependent benefits if the injury becomes serious or fatal.
For example, Linh T. Nguyen is marked Female and Married. A common edge case is a worker whose marital status recently changed; use the current status as of the injury date.
A common mistake is guessing marital status, which can misstate who qualifies for survivor benefits in a death claim. The misconception is that these boxes are intrusive busywork, but they directly affect dependent benefit calculations under Arizona law.
Box 8: Employer’s Name
This box asks for the employer’s legal business name. Write the exact registered name on your workers’ comp policy, not a casual “doing business as” nickname. The carrier matches this to the policy in Box 9.
For example, the restaurant owner enters Sonoran Table LLC rather than “Sonoran Table.” A common edge case is a business with multiple locations under one policy; use the policy-holder name, not the branch.
A common mistake is writing the storefront name instead of the legal entity, which can disconnect the report from the policy. The misconception is that any version of the name works, but a mismatch with the policy slows carrier processing.
Box 9: Policy Number
This box asks for your workers’ compensation policy number. Copy it exactly from your insurance declarations page, including any letters and dashes. This number is how the carrier links the injury to your coverage.
For example, Sonoran Table LLC enters policy number WC-AZ-3391882. A common edge case is a newly bound policy where the number is pending; enter the binder number and supplement once the policy number issues.
A common mistake is leaving Box 9 blank or entering an old policy number, which can bounce the report back and delay the entire claim. The misconception is that the carrier “knows who you are,” but without the policy number their system may not connect the report.
Box 10: Nature of Business
This box asks what kind of business you run, such as manufacturing, retail, or construction. Describe your main activity in a few plain words so the Commission understands the work setting. This helps classify the risk and the worker’s job.
For example, Sonoran Table LLC writes Full-service restaurant. A common edge case is a mixed business; name the activity the injured worker performed.
A common mistake is writing something vague like “services,” which forces follow-up questions. The misconception is that this box is decorative, but it supports the payroll class code in Box 20.
Boxes 11 and 12: Office Address and Telephone
Box 11 asks for your business office address with city, state, and ZIP, and Box 12 asks for your business phone number. Enter the address and number where the carrier and Commission should reach the employer. This is your contact point for all claim correspondence.
For example, the owner lists 1190 E. Camelback Rd, Phoenix, AZ 85014 and (602) 555-0100. A common edge case is a home-based business; use the address where you receive business mail.
A common mistake is listing the injury site instead of the office, which routes important mail to the wrong place. The misconception is that the worker’s address covers this, but the employer needs its own reachable contact on file.
Box 13: Date of Injury or Illness
This box asks the date the injury happened or the illness was diagnosed. Enter it in month, day, year order, such as 05/18/2026. For a sudden injury this is the accident date; for an illness it is the date it became known.
For example, Diego Ramirez enters 05/18/2026 for the day he cut his hand. A common edge case is a gradual injury like carpal tunnel, where you use the date the worker first connected symptoms to work.
A common mistake is guessing the date, which can wrongly suggest the one-year filing deadline was missed. The misconception is that an approximate date is fine, but the exact date controls the statute of limitations clock.
Boxes 14, 15, and 16: Time of Event, Time Began Work, Date Notified
Box 14 asks the time the event happened, Box 15 asks when the employee started work that day, and Box 16 asks the date you were notified of the injury. Enter clock times with A.M. or P.M. checked, and a date for Box 16. These fields show whether the injury fell within the work shift and start your reporting clock.
For example, Diego was injured at 2:30 P.M., began work at 9:00 A.M., and his manager was notified on 05/18/2026. A common edge case is an injury noticed after the shift; record the time the worker reports it.
A common mistake is leaving Box 16 blank, which hides whether you met the 10-day deadline. The misconception is that notification date is the same as injury date, but they can differ, and Box 16 is what starts your duty to file.
Boxes 17 and 18: Last Day of Work and Date of Return
Box 17 asks the last day the worker worked after the injury, and Box 18 asks the date they returned to work. Enter dates in month, day, year order, or leave Box 18 blank if the worker has not returned. These dates show whether the worker lost time, which affects wage benefits.
For example, Linh T. Nguyen strained her back, her last day worked was 06/01/2026, and Box 18 is left blank because she is still off. A common edge case is a worker who never missed a day; enter the injury date or mark no lost time.
A common mistake is leaving both blank when the worker is clearly off work, which hides a lost-time claim from the carrier. The misconception is that these dates are optional, but they decide whether the seven-day waiting period and wage benefits apply.
Boxes 19 through 22: Occupation, Class Code, Department, Department Number
Box 19 asks the worker’s job title when injured, Box 20 asks the payroll class code, Box 21 asks the assigned department, and Box 22 asks the department number. Fill each with the worker’s actual role and your internal codes. These tie the worker to the right payroll classification.
For example, Diego Ramirez is listed as Warehouse Associate, class code 8810, department Shipping, number 04. A common edge case is a worker who does multiple jobs; list the one performed at the time of injury.
A common mistake is guessing the class code, which can misstate premium and benefit math. The misconception is that the job title alone is enough, but the class code is what the carrier and Commission rely on for rating.
Box 23: Did Injury Occur on Employer Premises?
This box asks whether the injury happened on your property, with a Yes or No checkbox. Check the box that matches where the accident occurred. This helps establish whether the injury arose in the course of employment.
For example, Diego was hurt in the warehouse, so his employer checks Yes. A common edge case is a delivery driver injured off-site; check No and give the location in Box 24.
A common mistake is checking Yes automatically, which can misstate the facts on an off-site injury. The misconception is that off-premises means the claim is invalid, but many off-site injuries are still covered.
Box 24: Address or Location of Accident
This box asks where the accident happened, including city, county, state, and ZIP. Enter the precise location, even if it is your own address. The Commission uses this for jurisdiction and investigation.
For example, the warehouse address 2300 W. Lower Buckeye Rd, Phoenix, Maricopa County, AZ 85009 goes here. A common edge case is a remote job site; give the nearest street address or clear landmark.
A common mistake is writing “on site” with no address, which forces follow-up. The misconception is that the location is obvious, but the Commission needs it spelled out, including the county.
Boxes 25 and 26: What Was the Injury and Part of Body
Box 25 asks what the injury or illness was, and the form specifically says to name the body part and be more specific than “hurt,” “pain,” or “sore.” Box 26 asks the part of body injured. Describe the injury clearly, like the form’s own examples strained back, chemical burn, hand, or carpal tunnel syndrome.
For example, Linh T. Nguyen enters lumbar back strain in Box 25 and lower back in Box 26. A common edge case is multiple injuries; list each one rather than picking only the worst.
A common mistake is writing only “hurt” or “pain,” which the form warns against and which makes the carrier question the claim. The misconception is that vague is safer, but a precise description actually speeds approval because the adjuster knows what to authorize.
Boxes 27 and 28: Fatal and Date of Death
Box 27 asks whether the injury was fatal, Yes or No, and Box 28 asks the date of death if the employee died. Check the correct box, and enter the death date only if it applies. A “Yes” here triggers the 24-hour reporting rule.
For example, in a non-fatal claim Diego’s employer checks No and leaves Box 28 blank. A common edge case is a worker who dies days after the injury; check Yes and enter the actual date of death.
A common mistake is missing the 24-hour fatality deadline because the form was treated as routine, which can bring penalties. The misconception is that death claims follow the normal 10-day clock, but fatalities must be reported within 24 hours.
Boxes 29 and 30: Emergency Room and Overnight Hospitalization
Box 29 asks whether the worker was treated in an emergency room, and Box 30 asks whether they were hospitalized overnight as an in-patient. Each has a Yes or No checkbox, plus space for the physician or hospital name and address. These signal the severity of the injury to the carrier.
For example, Diego went to the ER, so the employer checks Yes on Box 29 and lists Banner Urgent Care, 1500 N. 24th St, Phoenix, AZ 85008. A common edge case is treatment at a clinic that is not an ER; check No on Box 29 and note the clinic elsewhere.
A common mistake is leaving the provider name blank, which delays the carrier’s request for medical records. The misconception is that the worker’s doctor will report this, but your form needs the provider details too.
Box 31: If Validity of Claim Is Doubted, State Reason
This box lets you state any reason you doubt the claim is valid. Write a short, factual reason if you have one, or leave it blank if you do not dispute the claim. This is where you flag concerns without refusing to file.
For example, an employer might write No witnesses; injury reported six days after alleged date if facts raise questions. A common edge case is a claim you partly accept; note only the specific doubt, such as whether it happened at work.
A common mistake is using this box to vent or accuse, which can backfire if the claim is later accepted. The misconception is that filing the report means you accept the claim, but Box 31 proves you can report and still dispute.
Boxes 32, 33, and 34: What Happened, Object That Harmed, Activity Before Incident
Box 32 asks how the injury occurred, Box 33 asks what object or substance directly harmed the worker, and Box 34 asks what the worker was doing just before the incident. Use the form’s example style, such as When ladder slipped on wet floor, worker fell 20 feet. Be specific about tools, equipment, and materials.
For example, Diego enters in Box 32 Box cutter slipped while opening a carton and sliced left palm, Box 33 box cutter, and Box 34 opening shipping cartons with a handheld box cutter. A common edge case is a gradual injury; Box 33 may be left blank and Box 34 describes the repetitive task.
A common mistake is a one-word answer like “fell,” which leaves the carrier guessing about cause. The misconception is that detail invites liability, but a clear cause story actually helps resolve the claim faster and supports any subrogation.
Box 35: Non-Employee Who Caused the Accident
This box asks for the name and address of any person not employed by your company who caused the accident. Fill it in if a third party was at fault, or leave it blank if not. This supports your carrier’s right to recover money from the at-fault party.
For example, if a delivery vendor’s driver hit your worker, you list FastFreight Inc., 900 S. Industrial Way, Tempe, AZ 85281. A common edge case is an unknown third party; note what you know, such as a license plate.
A common mistake is leaving it blank when a third party is clearly at fault, which costs your carrier a subrogation recovery and can raise your future premium. The misconception is that third-party details are not your concern, but reporting them can save you money.
Boxes 36 through 39: Worker in Your Employ, Hours, Overtime, Days per Week
Box 36 asks whether the worker was in your employ when injured, Box 37 asks hours per day worked with from and to times, Box 38 asks whether the worker was on overtime when injured, and Box 39 asks the usual number of days worked per week. Check the boxes and enter the times and numbers. These build the wage and coverage picture.
For example, Diego is marked Yes in Box 36, 9:00 A.M. through 5:30 P.M. in Box 37, No in Box 38, and 5 in Box 39. A common edge case is a part-time worker with irregular hours; give the typical schedule.
A common mistake is guessing the schedule, which throws off the wage calculation. The misconception is that these are throwaway fields, but they feed directly into the average monthly wage.
Boxes 40 through 47: Wage Data When Loss Exceeds Seven Days
The form says to complete Boxes 40 through 47 if work loss is expected to exceed seven calendar days. These cover date of last hire (40), whether the worker was paid for the day of injury (41), whether the job was permanent (42), months of work available per year (43), wage status by hour, day, week, or month (44), value of any lodging or board furnished (45), actual gross earnings for the 30 days before injury (46), and whether the worker claims dependents (47). Fill them all when the worker will miss more than a week.
For example, Linh T. Nguyen, off more than a week, enters last hire 03/01/2024, paid for day of injury Yes, $96, permanent Yes, months available 12, wage $22 per hour, no lodging, 30-day gross earnings $3,520, and dependents Yes. A common edge case is uncertainty about how long the worker will be out; if more than seven days is even likely, complete these boxes.
A common mistake is skipping these because you assume a quick return, which delays wage benefits if the worker stays out. The misconception is that the carrier figures wages on its own, but your reported earnings drive the benefit rate.
Boxes 48 through 55: Variable or Irregular Pay Data
The form says to complete Boxes 48 through 55 if the employee is paid other than a fixed weekly or monthly salary. These cover overtime pay basis (48), normal overtime hours per week (49), gross wages for the 12 months before injury (50), gross wages from hire date if less than 12 months (51), date of last wage increase within 12 months (52), wage before increase (53), wage after increase (54), and gross earnings from the date of increase through the day before injury (55). Complete these for hourly, tipped, commission, or piece-rate workers.
For example, a tipped restaurant server who earns variable pay would have her employer enter 12-month gross wages of $31,400 in Box 50 and a last raise date of 01/15/2026 in Box 52. A common edge case is a worker hired fewer than 12 months ago; use Box 51 for partial-year wages.
A common mistake is leaving these blank for an hourly worker, which understates the true average wage and shortchanges benefits or invites a dispute. The misconception is that only salaried data matters, but irregular pay needs this fuller picture to be fair.
Signature Block: Authorized Signature, Title, and Date
The bottom of the form asks for the authorized signature, the signer’s title, and the date. An owner, officer, or authorized HR representative signs, prints their title, and dates the form. After the 04/21/2026 streamlined update, the online version no longer requires an Adobe E-Sign.
For example, the restaurant owner signs, writes Owner/Member as the title, and dates it 06/02/2026. A common edge case is a third-party administrator filing for you; they sign and note their administrator role.
A common mistake is sending the form unsigned, which the carrier may reject as incomplete and bounce back, costing days. The misconception is that a typed name without authority is fine, but the signer must actually be authorized to bind the employer.
Three Filled-Out Examples Using Real Scenarios
These three scenarios show how three different employers complete Form ICA 0101 from start to finish.
Scenario 1: Minor injury, no lost time. Diego Ramirez, a warehouse associate, cuts his palm on a box cutter and returns to work the next day after stitches.
| Form Section | What Diego’s Employer Enters |
|---|---|
| Header (recordable) | Recordable; OSHA Case 2026-014 |
| Box 1 (name) | Ramirez, Diego |
| Box 13 (date of injury) | 05/18/2026 |
| Box 23 (on premises) | Yes |
| Box 25 (injury) | Laceration, left palm |
| Box 29 (ER) | Yes; Banner Urgent Care |
| Box 32 (what happened) | Box cutter slipped while opening a carton |
| Boxes 17/18 (lost time) | Last day 05/18/2026; returned 05/19/2026 |
| Signature | Owner, dated 05/20/2026 |
Scenario 2: Lost-time injury. Linh T. Nguyen, a restaurant cook, strains her lower back lifting a stock pot and is off work more than two weeks.
| Form Section | What Linh’s Employer Enters |
|---|---|
| Box 1 (name) | Nguyen, Linh T. |
| Box 9 (policy number) | WC-AZ-3391882 |
| Box 13 (date of injury) | 06/01/2026 |
| Box 25 (injury) | Lumbar back strain |
| Box 26 (part of body) | Lower back |
| Boxes 17/18 (lost time) | Last day 06/01/2026; return blank |
| Box 46 (30-day earnings) | $3,520 |
| Box 47 (dependents) | Yes |
| Signature | HR Manager, dated 06/03/2026 |
Scenario 3: Fatality requiring 24-hour notice. Robert Hale, a roofer, falls from a ladder and dies, so his employer must report within 24 hours.
| Form Section | What Robert’s Employer Enters |
|---|---|
| Header (recordable) | Recordable |
| Box 1 (name) | Hale, Robert J. |
| Box 13 (date of injury) | 05/22/2026 |
| Box 24 (location) | 4400 E. Indian School Rd, Phoenix, Maricopa County, AZ |
| Box 25 (injury) | Fatal fall, multiple trauma |
| Box 27 (fatal) | Yes |
| Box 28 (date of death) | 05/22/2026 |
| Box 32 (what happened) | Ladder slipped; worker fell approximately 20 feet |
| Signature | Owner, dated 05/22/2026 |
How to File the Completed Form
You have three filing channels, and each ends with copies going to the same places.
Online portal. File through the Industrial Commission’s online injury tool at azica.gov. There is no filing fee, no payment is needed, and electronic submission posts fastest, often the same day. After you submit, save the confirmation screen or email as your proof of filing.
By mail. Mail one copy to the Industrial Commission of Arizona, P.O. Box 19070, Phoenix, Arizona 85005-9070, and one copy to your insurance carrier at the address it provides. There is no fee. Use first-class mail or certified mail, allow several business days for delivery, and keep your certified mail receipt as proof of filing.
Through your carrier. Most private carriers accept Form ICA 0101 directly and forward it to the Commission. There is no fee, and processing time depends on the carrier, usually a few business days. Keep the carrier’s acknowledgment email or fax confirmation as your proof.
No matter the channel, the form’s own note tells employers to mail one copy to the Commission within 10 days, one copy to the carrier within 10 days, and keep one copy for at least five years as the OSHA supplementary record. Hold onto your copy and your proof of filing in case a deadline is ever questioned.
What Happens After You File
Once the carrier and Commission receive your report, the carrier opens a claim file and an adjuster reviews it. The adjuster contacts the worker, requests medical records, and decides within the statutory window whether to accept or deny the claim. Your report’s accuracy shapes how quickly that decision comes.
If the claim is accepted, the carrier begins paying medical bills and, for lost-time injuries beyond the seven-day waiting period, wage replacement based on the worker’s average monthly wage. The wage data you entered in Boxes 40 through 55 drives those payments, so errors there can mean disputes later.
If the carrier denies the claim, the worker can protest to the Commission and request a hearing before an administrative law judge. Your Box 31 notes about doubted validity may matter at that stage. Either way, the Commission keeps the file and tracks the claim through resolution.
Expect the carrier to follow up with you for missing details, such as a class code or wage figure. Respond fast, because delays on your end can extend the claim and frustrate everyone involved.
Mistakes to Avoid When Filling Out the Form
- Filing late. Missing the 10-day deadline can bring civil penalties and undermines your credibility with the carrier.
- Missing the 24-hour fatality rule. Treating a death like a routine claim can trigger penalties and a state investigation.
- Wrong or blank policy number in Box 9. The carrier cannot match the claim, so the whole report stalls.
- Vague injury description in Box 25. Writing only “hurt” or “pain” makes the adjuster question and slow-walk the claim.
- Transposed Social Security number in Box 2. A single wrong digit can create a duplicate file or route benefits to the wrong record.
- Blank notification date in Box 16. Without it, no one can confirm you met the 10-day clock.
- Skipping wage Boxes 40 through 55. Incomplete wage data delays or understates the worker’s benefit payments.
- Using a nickname in Box 1. Name mismatches with state records freeze the claim.
- Leaving the form unsigned. An unsigned report is incomplete and gets bounced back, costing days.
- Not keeping your copy for five years. Discarding it early breaks the federal OSHA recordkeeping rule and leaves you with no proof.
- Listing the injury site as the office in Box 11. Misrouted mail means you miss carrier and Commission notices.
- Guessing the class code in Box 20. A wrong code skews premium and benefit math and invites an audit.
Do’s and Don’ts
Do’s
- Do file within 10 days of notice, because the deadline is a legal duty under A.R.S. § 23-908.
- Do report fatalities within 24 hours, since the shorter clock carries stiffer consequences if missed.
- Do copy identifiers exactly from payroll, so names, SSNs, and birth dates match state records.
- Do describe the injury and cause in detail, because specifics speed the adjuster’s decision.
- Do keep your copy for five years, to satisfy the federal OSHA recordkeeping requirement.
- Do save your proof of filing, so you can show you met the deadline if it is ever questioned.
Don’ts
- Don’t treat filing as admitting fault, because reporting is a duty and Box 31 lets you dispute.
- Don’t leave the policy number blank, since the carrier cannot link the claim without it.
- Don’t guess wage figures, because errors lead to benefit disputes and corrections later.
- Don’t use vague injury words, as “hurt” or “pain” stalls the claim the form warns against this.
- Don’t skip the signature, because an unsigned form is rejected as incomplete.
- Don’t delay because details are missing, since a late form is worse than an incomplete one you supplement.
Pros and Cons of Filing on Your Own vs. With Help
| Filing on Your Own | Filing With a Carrier or TPA’s Help |
|---|---|
| Pro: No extra cost, because you handle it in-house. | Pro: Fewer errors, since claims pros know the boxes. |
| Pro: Faster start, as you do not wait on a third party. | Pro: Built-in deadline tracking reduces late filings. |
| Pro: Full control over how injury and cause are described. | Pro: Help with tricky wage math in Boxes 40 through 55. |
| Pro: Direct knowledge of the facts speeds Boxes 32 to 34. | Pro: Guidance on Box 31 disputes lowers legal risk. |
| Pro: Builds your own claims-handling experience. | Pro: A clean filing record can support premium reviews. |
| Con: Easy to miss the 10-day or 24-hour deadline. | Con: May add a service fee depending on the arrangement. |
| Con: Higher chance of field errors that delay claims. | Con: Less direct control over wording and timing. |
| Con: You alone bear the penalty risk for mistakes. | Con: Coordination can add a step before the report posts. |
| Con: Wage and class-code math can trip up non-experts. | Con: You still must supply accurate underlying data. |
| Con: No second set of eyes before submission. | Con: Reliance on a third party for your legal deadline. |
FAQs
Do I have to file Form ICA 0101 even if the injury seems minor?
Yes. You must report any injury or disease a worker claims arose from work, even minor ones, within 10 days of notice under A.R.S. § 23-908.
Does filing this form mean I admit the injury is work-related?
No. Filing is a legal reporting duty, not an admission, and Box 31 lets you state any reason you doubt the claim’s validity.
Do I write the worker’s last name or first name first in Box 1?
No. You do not start with the first name; Box 1 is formatted last name, then first name, then middle initial, matching the worker’s payroll and SSA records.
Do I have to enter the Social Security number in Box 2?
Yes. The Commission requires the SSN under a Privacy Act exception so it can tell apart workers with similar names and birth dates.
Do I fill in Boxes 40 through 47 for a one-day injury?
No. You complete Boxes 40 through 47 only when work loss is expected to exceed seven calendar days, per the form’s own instruction.
Do I report a workplace death on the normal 10-day timeline?
No. Fatalities must be reported within 24 hours, a much shorter clock than the standard 10 days for other injuries.
Do I leave Box 31 blank if I do not dispute the claim?
Yes. Box 31 is only for stating a reason you doubt validity, so you leave it blank when you accept the claim as reported.
Do I need the exact class code in Box 20?
Yes. The payroll class code drives premium and benefit calculations, so guessing it can cause an audit or a benefits dispute.
Do I keep a copy of the form after filing?
Yes. You must keep one copy for at least five years as the supplementary injury record required by the federal OSHA Act of 1970.
Do I file online or by mail?
Yes. Both work; the Commission offers an online injury tool that posts fastest, and you can also mail copies to P.O. Box 19070, Phoenix, AZ 85005-9070.
Do I still need an Adobe E-Sign on the form?
No. Effective April 21, 2026, the streamlined Employer’s Report of Injury no longer requires an Adobe E-Sign for the online version.
Do I have to fill in Boxes 48 through 55 for a salaried worker?
No. Those boxes apply only when the employee is paid other than a fixed weekly or monthly salary, such as hourly, tipped, or commission pay.
Do I list a third party in Box 35 if someone outside my company caused the injury?
Yes. You name and address any non-employee at fault, because it supports your carrier’s right to recover costs through subrogation.
Do I use the injury date or the notification date in Box 16?
No. Box 16 is the date you were notified, which can differ from the injury date in Box 13 and starts your 10-day filing clock.
Related reading
- How to Fill Out Illinois IWCC Application for Adjustment of Claim + FAQs
- How to Fill Out Washington L&I Application for Benefits (Form F242-130-000) + FAQs
- How to Fill Out the Arizona ICA Petition to Reopen (w/Examples) + FAQs
- How to Fill Out the Arizona ICA Request for Hearing (Form 0446) — With Examples + FAQs
- How to Fill Out the Arizona ICA Worker’s Report of Injury (With Examples) + FAQs
- How to Fill Out Colorado WC Employer’s First Report of Injury + FAQs
- How to Fill Out California WCAB DWC-AD 1 (w/Examples) + FAQs