The Arizona ICA settlement and lump sum petition is the document an injured worker files with the Industrial Commission of Arizona to either close a workers’ compensation claim for one final payment or convert future monthly award checks into a single up-front sum. A “Petition for Approval of Full and Final Settlement” closes a claim under A.R.S. § 23-941.01, while a “Petition for Lump Sum Commutation” turns awarded benefits into one payment under A.R.S. § 23-1067. Both land on the desk of an Administrative Law Judge, and both can be rejected if a single key box is wrong.
Money is the heart of this filing, and the stakes are high. A lump sum commutation of a scheduled award cannot top $25,000, an unscheduled award cannot top $150,000, and Arizona courts have made clear that the granting of a lump sum “seems to be the exception, rather than the rule.” Get the financial-betterment showing wrong and the Commission says no. This guide walks you through every line, every attachment, and every trap.
- 📄 How to tell a Full and Final Settlement apart from a Lump Sum Commutation and pick the right one
- 🧮 How to complete each field, attestation, and disclosure the ICA demands
- ⚖️ How to clear the “financial betterment” test that sinks most commutation requests
- 🩺 How to handle future medical, Medicare Set-Asides, and liens without losing your right to care
- ⏱️ How to file with the Chief Administrative Law Judge and protect your 10-day protest deadline
What the Form Is and Who Must File It
The Arizona ICA settlement or lump sum petition is a request that asks an Administrative Law Judge to approve a change in how your permanent benefits are paid or to close your claim for good. The agency that receives it is the Administrative Law Judge Division of the Industrial Commission of Arizona, located at 800 West Washington Street, Phoenix, AZ 85007. The petition exists because Arizona law normally requires permanent disability benefits to be paid monthly, and only a judge can override that rule.
Two separate statutes drive two separate forms. The first is the Full and Final Settlement, created by A.R.S. § 23-941.01, which became effective for settlements on or after August 3, 2018. This path lets a worker and the carrier agree to a one-time payment that closes the claim, including future indemnity and sometimes future medical care.
The second is the Lump Sum Commutation under A.R.S. § 23-1067, which does not close your claim but converts a portion of your awarded benefits into a single payment. A scheduled award can be commuted up to $25,000 with or without the carrier’s consent, while an unscheduled award can be commuted up to $150,000 only if the carrier consents. People who file include injured workers acting on their own, often called pro se filers, and attorneys filing on a worker’s behalf. Carriers and self-insured employers also sign these documents, since a Full and Final Settlement must be signed by both sides.
The deadline that governs both is the finality of your award. You may only file after your permanent disability award becomes final or after every party waives the right to appeal. The penalty for filing too early is simple: the Commission has no power to act, and your petition sits dead until the award is final.
Before You Start: Documents and Information You Need
Gather everything below before you open the petition, because a missing piece is the fastest way to a rejection or a delayed hearing. The ICA cross-checks each item against its own claim file, so mismatched names or numbers stall the review.
- Your ICA claim number. This is the unique number on every notice the Commission has mailed you. Without it the clerk cannot match your petition to your file, and it will not be processed.
- Your full legal name, date of birth, and current address. The judge uses these to confirm identity and to mail the award. A wrong address can mean you never see the decision and blow the 10-day protest window.
- The date of injury and employer name on that date. These anchor which claim is being settled. If you have more than one claim, list each one.
- The final award or notice of claim status. This proves your permanent disability is set and that you are eligible to file. Missing proof of finality means the petition is premature.
- The carrier’s medical disclosure. For a Full and Final Settlement, the carrier must disclose anticipated future medical costs and how they were calculated. Without it, the judge cannot approve the deal.
- The carrier’s indemnity disclosure. This includes your life expectancy, rated age, present value of future benefits, and the discount rate used. A blank here voids the agreement.
- A current bank or budget statement. For a commutation, you must show the lump sum leaves you better off. No financial proof, no approval.
- Medicare status and any Medicare Set-Aside (WCMSA) paperwork. If you are on Medicare or will be soon, you must show steps taken to protect Medicare. Skipping this can trigger federal recovery against you.
- A list of medical liens or unpaid charges. Both sides must search for and address liens. Hidden liens can come back to drain your settlement.
Where to Get the Form and How to Access It
Arizona does not post a single fill-in “settlement” PDF on its public website the way it posts routine claim forms. Instead, the ICA forms page hosts the routine workers’ compensation forms, and the Commission supplies the lump sum commutation packet on request. As the Industrial Commission of Arizona confirms, “upon request, the ICA will provide you with all the forms, which you will have to complete in full.”
For a Full and Final Settlement, there is no rigid agency template. The parties draft a “Petition for Approval of Full and Final Settlement” and a “Full and Final Settlement Agreement” that follow the statute and the agency’s Full and Final Best Practices document, effective August 3, 2018. You title the petition exactly that way, since the agency asks parties to avoid calling it a “compromise and settlement agreement.”
For a Lump Sum Commutation, call or visit the Claims Division to request the packet. You can reach the Phoenix office at (602) 542-4661 or the Tucson office through the same contact page. Confirm the revision date printed on any form the Commission sends, since the agency updates packets over time, and an outdated version can be rejected at intake.
Step-by-Step: How to Fill Out the Settlement / Lump Sum Petition Line by Line
This is the spine of the filing. Work through each field in the order it appears, use capital letters where the form calls for them, and write dates as MM/DD/YYYY. The fields below combine the captions used on the Lump Sum Commutation packet and the elements required for a Full and Final Settlement Petition.
Caption: Injured Worker Name
The caption at the top asks for the injured worker’s full legal name. This is the name the entire claim is filed under, so it sets the heading on every document the judge issues.
Write your name in full and in all capital letters, last name first if the form is structured that way, for example LOPEZ, MARIA G. Match it exactly to the name on your prior ICA notices, not a nickname. Maria Lopez, an injured warehouse worker, writes LOPEZ, MARIA G. because that is how her notice of claim status reads.
A common edge case is a name change after marriage or divorce. If your legal name changed since the injury, use your current legal name and add a short note listing the former name so the clerk can match the file. The most common mistake here is using a shortened or nickname version, which can cause the clerk to fail to match your petition to your claim, leaving it unprocessed. A frequent misconception is that any version of your name will do, but the Commission matches names against its existing claim record, so precision matters.
Field 1: ICA Claim Number
This field asks for the claim number the Commission assigned when your injury was first reported. It is the single most important identifier on the page.
Copy the number exactly from any official ICA notice, including all digits and dashes, for example 20231234567. Do not guess or round it. Carlos Nguyen, a roofer with a back injury, writes his claim number 20221045566 straight from his award letter.
If you have more than one claim being settled or commuted, list every claim number, since each is a separate legal matter. The most common mistake is transposing two digits, which routes your petition to the wrong file or to no file at all and stalls everything. People often believe the claim number and the carrier’s internal file number are the same, but they are not, and only the ICA claim number works here.
Field 2: Date of Injury and Employer
This field asks when you were hurt and who you worked for on that date. These facts tie the petition to a specific compensable injury.
Enter the date as MM/DD/YYYY and the employer’s full legal business name, for example 08/14/2022 and DESERT FREIGHT LLC. Use the employer name on the date of injury, even if you no longer work there. Janet Brooks, hurt after a 22-year career, writes 03/02/2024 and VALLEY MEDICAL GROUP INC.
If you had two injuries on two dates under two employers, list both, since each may carry its own award. The most common mistake is entering the date you reported the injury instead of the date it happened, which can conflict with the claim record. A widespread misconception is that a current employer name belongs here, but the field always points to the employer at the time of injury.
Field 3: Type of Award Being Settled or Commuted
This field asks whether your award is scheduled or unscheduled and what kind of benefits you are settling or commuting. The answer controls the dollar caps and whether the carrier must consent.
Mark whether the award is a permanent partial scheduled award or an unscheduled award, and identify indemnity, future medical, or both. For a commutation, note the monthly benefit amount, for example $642.00 per month. Carlos marks unscheduled and lists $1,100.00 per month in loss-of-earning-capacity benefits.
The edge case is a claim with both scheduled and unscheduled features after multiple injuries; describe each separately. The most common mistake is mislabeling an unscheduled award as scheduled, which sets the wrong cap and can void the request, since the $25,000 limit applies only to scheduled awards and $150,000 to unscheduled. Many filers wrongly believe all awards can be fully cashed out, but the statutory caps are firm.
Field 4: Amount Requested and Computation
This field asks for the dollar amount you want and how it was figured. The Commission values a commutation as of the day you file the request.
State the requested lump sum and attach the math, since the ICA subtracts advances and payments made after the request date and then discounts the value. For a commutation the discount runs at the statutory rate set by Ariz. Admin. Code R20-5-122. Maria requests $24,000.00 against her scheduled award and attaches a one-page calculation.
If payments are still being issued while your request is pending, expect the final figure to shift, since the value is fixed on the filing date and reduced by later payments. The most common mistake is requesting more than the statutory cap, which draws an automatic denial. A common misconception is that the lump sum equals the simple total of remaining monthly checks, but present-value discounting lowers it.
Field 5: Reason for the Request (Financial Betterment Showing)
This is the field that decides most lump sum cases. You must explain why a single payment leaves you better off financially or advances your rehabilitation.
Write a clear, specific statement showing that the lump sum will generate more net income or opportunity than the monthly checks, since the Commission only grants a commutation when the facts “demonstrate a reasonable basis for financial betterment or rehabilitation.” Tie the money to a concrete plan, for example paying off a 9% debt, buying tools for a new trade, or stopping a foreclosure. Carlos writes that he will use $45,000 to launch a home-inspection business that nets more than his monthly award.
The edge case is a request to simply “have the money,” which courts reject; you need a plan that beats the status quo. The most common mistake is a vague reason like wanting to “pay bills,” which fails the betterment test and draws a denial. A deep misconception is that hardship alone wins approval, but the real question the judge asks is whether the lump sum will generate more net monthly income than you now receive.
Field 6: Medical Disclosure (Full and Final Settlements)
For a Full and Final Settlement, this section requires the carrier’s written disclosure of future medical care. Under A.R.S. § 23-941.01(C)(2), it must spell out anticipated future medical, surgical, and hospital benefits, their projected cost, how that cost was determined, and how much of the settlement covers future medical.
Attach the carrier’s disclosure and confirm each of the four parts is present. Do not draft this yourself; it comes from the carrier. Janet attaches a disclosure projecting $38,000 in future care and noting $30,000 of her settlement covers it.
The edge case is a claim where future medical stays open; then this disclosure may be narrower, but it still must appear. The most common mistake is filing without the cost methodology, which leaves the judge unable to approve the deal. Many workers assume the carrier’s number is final, but you can question it before you sign.
Field 7: Indemnity Disclosure (Full and Final Settlements)
This section requires the carrier’s written disclosure of future indemnity, or wage-loss, benefits. Under A.R.S. § 23-941.01(C)(3), it must list the total future indemnity, your rated age if used, your life expectancy and its source, the present value of those benefits, the discount rate, and the portion of the settlement covering indemnity.
Attach the disclosure and read every figure. Confirm the life-expectancy source is named and the discount rate is stated. Aisha Carter, a delivery driver settling a long-term claim, checks that her disclosure lists a present value of $96,500 and a 3% discount rate.
The edge case involves a rated age, where a medical condition makes your insurance-rated age older than your real age, raising present value; make sure it is applied if it helps you. The most common mistake is accepting a disclosure missing the discount rate, which makes the present value unverifiable and stalls approval. A misconception is that present value equals lifetime benefits, but discounting always reduces it.
Field 8: Injured Worker Attestations
A Full and Final Settlement requires you to sign sworn statements. Under A.R.S. § 23-941.01(C)(1), you must attest that you read and understand the agreement, including the rights you give up.
Sign each attestation only after you understand it, since you confirm you grasp that you are releasing the right to rearrange permanent benefits under A.R.S. § 23-1044(F) and the right to reopen under A.R.S. § 23-1061(H). You also attest you had a chance to hire a lawyer, and, if you chose not to, that you knowingly declined. Marcus Reed signs after a paragraph stating he understands he is releasing his right to reopen for these settled conditions.
The edge case is an unrepresented worker; the judge will hold a hearing to question you directly about every attestation. The most common mistake is signing without reading, which can later bind you to terms you did not understand. A dangerous misconception is that you can undo a Full and Final Settlement after approval, but it is final once the award is final.
Field 9: Future Medical Set-Aside Attestation
This attestation, required by A.R.S. § 23-941.01(C)(4), confirms you understand that money received for future treatment should be set aside to pay for that treatment. The judge wants to see you have a plan.
State how you plan to set the money aside, for example placing $30,000 in a dedicated account used only for injury-related care. Do not leave this blank or generic. Janet writes that she will open a separate savings account and pay only injury-related bills from it.
The edge case is a Medicare beneficiary, where a formal Workers’ Compensation Medicare Set-Aside, or WCMSA, may be needed under CMS rules. The most common mistake is treating the settlement as spending money, which can leave you paying out of pocket for care you settled away. A misconception is that the carrier keeps paying treatment after a full and final medical settlement, but that responsibility shifts to you.
Field 10: Party Attestations (Medicare, Liens, No Coercion)
A Full and Final Settlement requires all parties to sign attestations covering compliance. Under A.R.S. § 23-941.01(C)(5), (C)(6), and (C)(7), the parties confirm they protected Medicare, Medicaid, the Indian Health Service, and VA interests, searched for and addressed medical liens, and used no coercion or fraud.
Make sure both signatures appear and that the Medicare discussion names the steps taken, such as obtaining a WCMSA or documenting why none is needed. Aisha and the carrier both sign a statement listing a completed lien search and a WCMSA review.
The edge case is a claim with an unsatisfied lien; it must be disclosed and addressed before approval. The most common mistake is a bare checkbox with no explanation, which the judge can treat as incomplete. A misconception is that Medicare’s interests are the carrier’s problem alone, but the worker shares responsibility.
Field 11: Signature and Date Block
The final block asks for your signature and the date. This is the legal act that makes the petition real.
Sign in ink, print your name beneath, and date it MM/DD/YYYY, for example 05/30/2026. A Full and Final Settlement Agreement must be signed by both the worker (or the worker’s representative) and the carrier, Special Fund, or self-insured employer. Carlos signs and dates his commutation request the same day he files it, since the value is fixed on that date.
The edge case is a represented worker, where an authorized representative may sign; the signature line should reflect that authority. The most common mistake is leaving the date blank, which clouds the valuation date for a commutation. A misconception is that a typed name counts as a signature; the Commission expects an actual signature.
Three Filled-Out Examples Using Real Scenarios
These three named filers show how the petition looks from start to finish. Each represents a common path through the Arizona system.
Scenario 1 — Maria Lopez, scheduled award, small lump sum to stop foreclosure
| Form Section | What Maria Enters |
|---|---|
| Injured Worker Name | LOPEZ, MARIA G. |
| ICA Claim Number | 20231234567 |
| Date of Injury and Employer | 11/05/2023, SUNRISE LOGISTICS INC. |
| Type of Award | Permanent partial scheduled award |
| Amount Requested | $24,000.00 (within the $25,000 scheduled cap) |
| Reason for Request | Pay off mortgage arrears to stop foreclosure and lower monthly housing cost |
| Carrier Consent Needed? | No — scheduled awards under $25,000 need no carrier consent |
| Signature and Date | Maria G. Lopez, 05/30/2026 |
Scenario 2 — Janet Brooks, unscheduled award, full and final closure with medical buyout
| Form Section | What Janet Enters |
|---|---|
| Injured Worker Name | BROOKS, JANET L. |
| ICA Claim Number | 20189988776 |
| Date of Injury and Employer | 03/02/2024, VALLEY MEDICAL GROUP INC. |
| Type of Award | Unscheduled award, settling indemnity and future medical |
| Medical Disclosure | Future care projected at $38,000; $30,000 of settlement covers it |
| Indemnity Disclosure | Present value $96,500, 3% discount rate |
| Set-Aside Plan | Open dedicated account; pay only injury-related care |
| Signature and Date | Janet L. Brooks and carrier representative, 05/28/2026 |
Scenario 3 — Carlos Nguyen, unscheduled award, partial commutation for rehabilitation
| Form Section | What Carlos Enters |
|---|---|
| Injured Worker Name | NGUYEN, CARLOS T. |
| ICA Claim Number | 20221045566 |
| Date of Injury and Employer | 08/14/2022, DESERT FREIGHT LLC |
| Type of Award | Unscheduled award (carrier consent required) |
| Amount Requested | $45,000.00 (within the $150,000 unscheduled cap) |
| Reason for Request | Start a home-inspection business projected to net more than monthly award |
| Future Reopening | Notes a commutation does not waive the right to reopen |
| Signature and Date | Carlos T. Nguyen, 05/29/2026 |
How to File the Completed Form
Arizona accepts these petitions through a few channels, and the right one depends on which petition you file. Keep a stamped copy of everything, since proof of filing protects your deadlines.
By mail or in person (Full and Final Settlements). File the Petition for Approval of Full and Final Settlement and the signed agreement with the Administrative Law Judge Division at 800 West Washington Street, Phoenix, AZ 85007, Attention: Chief Administrative Law Judge. There is no filing fee for the petition. Keep your mailing receipt or a date-stamped copy as proof, since processing depends on a complete package and can take weeks while the judge reviews and may set a hearing.
By request packet (Lump Sum Commutations). Request the commutation packet from the Claims Division, complete it in full, attach all documentation, and return it as the Commission directs, in person or by mail to the same Phoenix address. The ICA then asks the carrier for an opinion and, where appropriate, sends your request to the Commissioners. Keep a copy of the full packet you submitted.
By phone for the packet. To start a commutation, call the Phoenix office at (602) 542-4661 or use the ICA contact page to reach Tucson. Payment of an approved Full and Final Settlement must be made within fifteen days after the approving award becomes final, so confirm the carrier’s payment method and timing in writing before you sign.
What Happens After You File
Once your petition is in, an Administrative Law Judge reviews it under A.R.S. § 23-941.01(D)–(F) for settlements or the Commissioners review it for commutations. The judge can ask for more documents or hold a hearing, and you should respond fast, since delay stalls approval.
If you are unrepresented in a Full and Final Settlement, the judge must hold a hearing to question you directly about your attestations, including whether you understand the rights you are releasing and your duty to protect future treatment costs and other payers. The judge then approves or rejects the agreement in written findings and an award.
For a commutation, the ICA issues an award approving or disapproving the request. If your request is denied, you must protest within ten days by filing a signed Request for Hearing with the Commission. Failure to protest within ten days makes the decision final, and you lose the chance to challenge it. An approved Full and Final Settlement is paid within fifteen days after the award becomes final.
Mistakes to Avoid When Filling Out the Form
Each field is its own chance to slip. These errors most often sink a petition.
- Wrong or transposed ICA claim number. The petition cannot be matched to your file and sits unprocessed.
- Filing before the award is final. The Commission has no jurisdiction and your petition is dead on arrival.
- Requesting more than the statutory cap. Asking over $25,000 on a scheduled award or $150,000 on an unscheduled award draws an automatic denial.
- Mislabeling a scheduled award as unscheduled or vice versa. The wrong dollar cap and consent rule apply, voiding the request.
- A vague “I need money” reason. It fails the financial-betterment test and the commutation is denied.
- Filing a Full and Final Settlement without the medical disclosure. The judge cannot evaluate future care and rejects the package.
- Filing without the indemnity disclosure or discount rate. Present value is unverifiable and the agreement stalls.
- Skipping the Medicare/WCMSA attestation. You risk federal recovery and a rejected settlement.
- Ignoring medical liens. Unsatisfied liens can later drain your settlement money.
- Leaving the signature or date blank. An unsigned or undated petition is invalid and, for commutations, clouds the valuation date.
- Calling a settlement a “compromise and settlement agreement.” The agency asks you to avoid that caption, and wrong titling slows intake.
- Missing the 10-day protest deadline after a denial. The decision becomes final and your options close.
Do’s and Don’ts
Do: – Do read every attestation before signing, since signing binds you to terms you may not undo. – Do match your name and claim number to your ICA notices, because the agency cross-checks them. – Do show a concrete financial-betterment plan, since that is the test the Commission applies. – Do attach both the medical and indemnity disclosures, because the judge cannot approve without them. – Do address Medicare and liens up front, since they protect you from later recovery actions. – Do keep a date-stamped copy of your filing, because it proves you met your deadlines.
Don’t: – Don’t file before your award is final, since the Commission cannot act. – Don’t request more than the statutory cap, because it triggers an automatic denial. – Don’t treat settlement money as spending cash, since you may owe for future care. – Don’t sign a disclosure missing the discount rate, because the value cannot be verified. – Don’t ignore a denial, since the 10-day protest window closes fast. – Don’t assume you can reopen after a Full and Final Settlement, because it ends those rights.
Pros and Cons of Filing on Your Own vs. With Help
Deciding whether to file alone or hire counsel shapes your odds, especially because commutations are granted as the exception, not the rule.
Pros of filing pro se: – You save attorney fees, since no contingency comes off your award. – You control the timing and the wording of your request. – For a small scheduled commutation under $25,000, the math and consent rules are simpler. – You keep the full lump sum if approved, with nothing deducted for help. – You learn your claim deeply, which helps if you later need to act fast.
Cons of filing pro se: – The financial-betterment test is hard to satisfy alone, and most denials turn on it. – An unrepresented Full and Final Settlement triggers a judge’s detailed hearing into your understanding. – Medicare Set-Aside and lien rules are complex and easy to get wrong. – A denied commutation can push you into hearings and even the Arizona Court of Appeals. – One missed deadline or disclosure can void months of effort.
FAQs
Do I have to wait until my award is final before I can file?
Yes. You may only file after your permanent disability award becomes final or all parties waive the right to appeal, because the Commission has no power to act before then.
Can I get my whole award as one lump sum?
No. A scheduled award caps at $25,000 and an unscheduled award caps at $150,000, and present-value discounting further reduces the figure.
Do I need the carrier’s consent for a commutation?
No for a scheduled award up to $25,000, but yes for an unscheduled award up to $150,000, where the carrier must consent.
Does a lump sum commutation give up my right to reopen my claim?
No. A commutation does not waive your right to reopen based on a change in your physical condition, though the lump sum is counted in any future adjustment.
Do I write my maiden name or married name in the name field?
No, do not guess; use your current legal name and add a note listing any former name so the clerk can match your existing claim file.
Do I enter the date I reported the injury in the date-of-injury field?
No. Enter the date the injury actually happened, formatted MM/DD/YYYY, since the report date can conflict with the claim record.
Do I have to fill in the financial-betterment section for a commutation?
Yes. You must show the lump sum leaves you better off financially or advances rehabilitation, because that is the exact test the Commission applies.
Do I include the discount rate in the indemnity disclosure box?
Yes. The disclosure must state the discount rate and life-expectancy source, or the present value cannot be verified and approval stalls.
Can I undo a Full and Final Settlement after it is approved?
No. Once the approving award becomes final, the settlement is binding and you cannot reopen the conditions you settled.
Do I have to address Medicare even if I am not yet 65?
Yes. If you receive or expect to receive Medicare, you must show steps to protect its interests, which may include a Medicare Set-Aside.
Do I owe a filing fee to submit the petition?
No. There is no filing fee to submit a Petition for Approval of Full and Final Settlement to the Administrative Law Judge Division.
Do I lose my rights if I miss the protest deadline after a denial?
Yes. Failure to file a signed Request for Hearing within ten days makes the decision final and ends your chance to challenge it.
Do I sign the petition myself if I have a lawyer?
No, your authorized representative may sign for you, but the signature line should reflect that authority and a Full and Final Settlement still needs both sides’ signatures.
Do I have to list every claim if I have more than one injury?
Yes. List each ICA claim number and date of injury separately, since each is its own legal matter with its own award and cap.
Related reading
- How to Fill Out Michigan WDCA Petition for Lump Sum Settlement + FAQs
- How to Fill Out Arizona Form 140ES (w/Examples) + FAQs
- How to Fill Out Arizona ICA Employer’s Report of Injury (w/Examples) + 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 California WCAB DWC-AD 1 (w/Examples) + FAQs