How to Fill Out the Arizona ICA Worker’s Report of Injury (With Examples) + FAQs

The Arizona Worker’s Report of Injury is ICA Form 0407 (Rev. 05.15.17), the form an injured worker files with the Industrial Commission of Arizona to open a workers’ compensation claim after a job-related injury or illness. You fill it out yourself, sign it, and send it to the state so the Commission can assign a claim number and put your employer’s insurance carrier on notice.

This one page decides whether your medical bills get paid and whether you receive money for lost wages while you heal. Arizona law gives you only one year from the date of injury to file, and a claim that lands even one day late can be barred forever. The Industrial Commission processes tens of thousands of injury claims every year, and a large share of delays trace back to simple blank boxes, wrong dates, and missing signatures on this very form.

Here is what you will learn in this guide:

• 📋 What Form 0407 is, who must file it, and the law that backs it up
• 🗂️ Every document and number to gather before you write a single word
• ✍️ A line-by-line walkthrough of all 23 questions, with sample answers
• 👷 Three real-life scenarios showing exactly what to write in each box
• ⏱️ How to file online, by mail, or by fax, plus what happens after you send it

What the Form Is and Who Must File It

The Worker’s Report of Injury is the legal document that starts a workers’ compensation claim in Arizona. When you sign and submit Form 0407, you are formally telling the Industrial Commission of Arizona (ICA) that you were hurt at work and that you want the benefits the law allows. The Commission then stamps your claim with a number, alerts your employer, and notifies the employer’s insurance carrier so the carrier can accept or deny the claim.

The person who files this form is the injured worker, not the employer. Your employer files a separate document called the Employer’s Report of Injury, known as Form 0101, within ten days of learning about your accident. The two reports cover the same event from two sides, and the ICA matches them together inside one claim file. You do not have to wait for your employer to act before you file your own report.

The legal engine behind this form is Arizona Revised Statutes § 23-1061, the statute that requires injured workers to file their claim with the Commission within one year. In plain English, this law says you have a deadline, and the clock starts on the day you knew or should have known your injury was work-related. If you ignore the deadline, the consequence is severe: the Commission can refuse your claim and you lose the right to medical and wage benefits for that injury. For example, Diego slips on a wet floor in March but waits 14 months to file, and the carrier denies his claim purely on timing even though the fall clearly happened at work. A common misconception is that telling your boss about the injury is the same as filing a claim, but a verbal report to a supervisor does not satisfy the statute. Only a report filed with the ICA, or the pink combined form filled out at the doctor’s office, counts as your legal claim.

You must file Form 0407 if you suffered an injury, illness, or condition caused by your job and you are an employee covered by Arizona workers’ compensation, which covers most private and public employees in the state.

Before You Start: Documents and Information You Need

Filling out Form 0407 goes faster and cleaner when you collect your facts first. The form asks for names, dates, numbers, and a short story of the accident, so gather everything before you open the page. Missing details force you to leave boxes blank, and blank boxes slow the Commission down or invite the carrier to question your claim.

Use this pre-filing checklist and pull each item together before you begin:

• Your full legal name and Social Security number, because the ICA uses the SSN to match every document to the right claim file, and a missing number can leave your paperwork floating unattached.
• Your current mailing address and phone number, because every decision, notice, and check gets mailed to the address on this form, and an old address means you miss deadlines.
• Your employer’s exact legal name, address, and phone number, because the Commission must identify the correct business and its insurance carrier, and a wrong name can route your claim to the wrong company.
• The date and time you were hired and your job title, because these set up how your average monthly wage is calculated for any lost-wage benefits.
• Your hourly wage and hours worked per day and week, because the carrier uses these numbers to figure how much your wage-loss checks should be.
• The exact date, time, and location of the injury, because these anchor your claim to a specific covered event and feed the one-year deadline calculation.
• The names, addresses, and phone numbers of any witnesses, because witness contact information supports your version of events if the carrier disputes the claim.
• The name and address of the doctor, clinic, or hospital that treated you, because the ICA and carrier need your medical records to confirm the injury and approve treatment.
• Details of any prior work injuries or disability payments, because the form asks about your injury history and an honest answer prevents fraud accusations later.

Where to Get the Form and How to Access It

Form 0407 lives on the official Industrial Commission of Arizona website, and the safest place to get it is straight from the agency. Go to the ICA’s Worker’s Report of Injury page, where the Commission offers the form as an online webform you can complete in your browser. The same page links a downloadable PDF version you can print, fill out by hand, and mail or fax.

Always confirm you have the current version before you start. The revision date printed in the bottom corner of the form should read Rev 05.15.17, which is the version in use. Older printouts floating around the internet may use outdated mailing instructions, so pulling the form fresh from azica.gov protects you from sending it to the wrong place.

The form is also available in Spanish as the Formulario de informe de lesión del trabajador, so a Spanish-speaking worker can read and complete it in their own language. If you cannot use a computer, you can call the ICA Claims Division at (602) 542-4661 and request the document, and staff can mail it or provide it in an alternative format. A common misconception is that you must buy the form or get it from a lawyer, but the form is free and the ICA makes it available to any worker directly.

Step-by-Step: How to Fill Out Form 0407 Line by Line

The form is a single page with 23 numbered questions. Work top to bottom, answer every question fully, and use the back of the page if you run out of room. The instruction at the top is blunt: ANSWER ALL QUESTIONS FULLY. Below is each numbered item with plain-English meaning, how to answer, a sample entry, an edge case, a common mistake, and a misconception to avoid.

Question 1: Name of Injured Worker, Social Security #, Birth Date, Phone

This box asks who you are. Enter your LAST, FIRST, and middle initial (M.I.) in the labeled spaces, then your Social Security number, birth date, and phone number.

Write your name exactly as it appears on your Social Security card, in all capital letters, and use the format MM/DD/YYYY for your birth date. Maria Gonzalez writes GONZALEZ under LAST, MARIA under FIRST, L under M.I., her SSN as 123-45-6789, birth date 03/14/1985, and phone (602) 555-0148.

If you go by a nickname or recently changed your last name, use your full legal name from your SSN card, not the nickname. A common mistake is leaving the Social Security number blank because it feels private, but the ICA uses it to link every record in your file, and without it your documents can sit unmatched and unprocessed. A misconception is that giving your SSN here is optional; the form notes the number is required under a pre-1975 rule permitted by the federal Privacy Act, because workers with similar names and birth dates can only be told apart by SSN.

Question 2: Address, City, State, Zip Code

This box asks where you live and where the Commission should mail everything.

Enter your full current mailing address, including street, city, state, and zip code, and double-check the zip. Maria enters 4521 N 7TH AVE, PHOENIX, AZ, 85013.

If you use a P.O. Box, write the P.O. Box here, since the ICA mails notices and checks to this exact address. A common mistake is listing an old address you have moved away from, which means notices of decision and benefit checks go to the wrong place and you can miss the short 90-day window to protest a denial. A misconception is that the ICA will track you down if you move; it will not, so you must update your address in writing if it changes.

Question 3: Marital Status and Dependents at Time of Injury

This box asks whether you were SINGLE, MARRIED, or DIVORCED, and whether you had DEPENDENTS AT TIME OF INJURY: YES / NO.

Check the one box that described you on the date of injury, and mark YES or NO for dependents. Maria checks MARRIED and marks YES because she supports two children.

If you separated but are not legally divorced, you are still married for this box. A common mistake is reporting your status today instead of your status on the injury date, which matters because dependents can affect death benefits if a claim becomes fatal. A misconception is that marital status changes your medical benefits; it does not, but it can affect survivor benefits and is part of your complete record.

Question 4: Employer and Phone

This box asks for the company you worked for when you got hurt and its phone number.

Write the employer’s full legal business name, not a store nickname or a manager’s name, and add the main phone number. Maria enters DESERT FRESH GROCERS INC and (602) 555-0200.

If you work for a staffing agency placed at another company, list the staffing agency that pays you, since that is usually your legal employer. A common mistake is writing a brand or location name like “the Phoenix store,” which can route your claim to the wrong business and delay carrier identification. A misconception is that your employer must fill in this box; you fill it in, because this is your report.

Question 5: Employer Address, City, Zip Code

This box asks where your employer is located.

Enter the employer’s business street address, city, and zip code. Maria writes 1200 W INDIAN SCHOOL RD, PHOENIX, 85013.

If your employer has many locations, use the address of the location where you actually worked or the company’s main office. A common mistake is leaving this blank because you assume the ICA already has it, but the Commission needs the address to confirm the correct employer and its policy. A misconception is that the home office in another state goes here; use the Arizona work location tied to your job.

Question 6: Date Hired, Where Hired, Occupation

This box asks when and where you started the job and what your job was.

Enter your hire date in MM/DD/YYYY format, the city where you were hired, and your job title. Maria enters 06/01/2021, PHOENIX, and CASHIER.

If you do not remember the exact hire date, give your best honest estimate and note it is approximate. A common mistake is guessing a wildly wrong date, which can throw off the wage calculation that controls your benefit amount. A misconception is that occupation means your department; it means your actual job duty, like CASHIER or FORKLIFT OPERATOR.

Question 7: Hours Worked Per Day, Per Week

This box asks your normal work schedule.

Enter the typical number of hours you work each day and each week. Maria writes 8 per day and 40 per week.

If your hours change week to week, give a fair average of a normal week. A common mistake is reporting only the hours on the injury day rather than your usual schedule, which understates your wage base. A misconception is that overtime never counts; your regular schedule belongs here, and overtime patterns can factor into the wage calculation the carrier performs later.

Question 8: Did You Receive Food or Lodging in Addition to Wage?

This box asks whether your pay included room, meals, or other in-kind value on top of cash wages.

Mark YES or NO. Maria marks NO because she earns cash wages only.

If your employer provided housing, free meals, or tips counted toward pay, mark YES, because that value can raise your average monthly wage. A common mistake is marking NO when you actually got lodging or regular meals, which can shrink your wage-loss checks. A misconception is that only cash counts as wages; Arizona can include the value of food and lodging when figuring your benefits.

Question 9: Date of Injury, Hourly Wage, Time of Injury

This box asks for the date and time you were hurt and your hourly pay.

Enter the date as MO/DAY/YEAR, your hourly wage, and the time of injury with AM or PM marked. Maria enters 02/10/2026, $18.50, and 2:30 PM.

If your injury developed over time, such as a repetitive-strain condition, use the date you first knew it was work-related or the date you first missed work. A common mistake is leaving the date blank or guessing, which is dangerous because this date starts the one-year filing deadline and anchors your whole claim. A misconception is that the time of day does not matter; it helps confirm the injury happened during your work hours.

Question 10: Address or Location of Accident

This box asks exactly where the accident happened.

Describe the specific spot, such as the store aisle, warehouse dock, or job site address. Maria writes AISLE 6, DESERT FRESH GROCERS, 1200 W INDIAN SCHOOL RD, PHOENIX.

If you were hurt off-site while doing a work errand, give that off-site address and note you were on the job. A common mistake is writing only the city, which is too vague to confirm the injury was work-related. A misconception is that the location must be your employer’s address; it is wherever you physically were when injured, even a customer’s site.

Question 11: Did You Stop Work Immediately? When Did You Stop?

This box asks whether you kept working after the injury or stopped, and when.

Answer whether you stopped, and if so give the date and time. Maria answers YES, stopped 2:45 PM on 02/10/2026.

If you finished your shift in pain and stopped the next day, say that plainly with the later date. A common mistake is saying you never stopped when you actually did, which can confuse your lost-time benefits. A misconception is that working through pain hurts your claim; it does not bar a claim, but you should report the timeline accurately.

Question 12: When Did You Report the Injury? To Whom? Title

This box asks when you told your employer and who you told.

Enter the date you reported, the person’s name, and their job title. Maria writes 02/10/2026, JAMES REED, STORE MANAGER.

If you reported by text or email, use that date and name the person. A common mistake is leaving this blank or writing “I told someone,” because the carrier looks hard at how quickly you reported. A misconception is that late reporting automatically kills a claim; Arizona has limited exceptions for late notice, but prompt reporting always helps your credibility.

Question 13: When Did You Return to Work? Regular Work / Other Work

This box asks whether and when you came back, and whether to your regular job or different duties.

Enter the return date and mark REGULAR WORK or OTHER WORK. Maria writes not yet returned because she is still off under doctor’s orders.

If you returned on light duty, mark OTHER WORK and note the date. A common mistake is leaving it blank when you have returned, which can cause overpayment or underpayment of wage benefits. A misconception is that returning to work ends your claim; you can return and still receive medical care and a permanent award for lasting impairment.

Question 14: Names of Persons Who Saw the Accident

This box asks for witnesses, with two slots for name, address, and phone.

List each witness with full name, address, and phone number. Maria lists witness 1: LUIS PARRA, 88 E CAMELBACK RD, PHOENIX, (602) 555-0312.

If no one saw it, write NONE rather than leaving it blank. A common mistake is leaving this empty when witnesses exist, which weakens your proof if the carrier disputes how the injury happened. A misconception is that you need a witness to win; many valid claims have none, but listing one strengthens your case.

Question 15: Was Accident Caused by Another Person? If So, by Whom?

This box asks whether someone else caused your injury.

Answer YES or NO, and if YES, name the person or company. Maria answers NO.

If a non-co-worker, like a careless delivery driver, caused the injury, name them, because the ICA and carrier may pursue a third-party claim. A common mistake is naming a co-worker to assign blame, which is usually irrelevant since workers’ comp is no-fault. A misconception is that fault decides your claim; comp pays regardless of who was at fault, but third-party details still matter.

Question 16: Name of Machine or Tool Which May Have Caused the Accident

This box asks what equipment, if any, was involved.

Name the specific machine, tool, or object. Marcus, a warehouse worker, writes PALLET JACK, MODEL 5000.

If no machine was involved, write N/A. A common mistake is vague entries like “a machine,” which slow any safety review and weaken the record. A misconception is that naming the tool blames you; it simply documents the cause and can support the claim.

Question 17: State How Accident Happened

This box is the heart of the form. It asks for the story of your injury in your own words.

Write a clear, factual account of what you were doing and how you got hurt, using the back of the form if needed. Marcus writes I was pulling a loaded pallet jack up the dock ramp when it rolled back and pinned my lower back against a steel post.

If your condition built up over time, explain the repeated task, such as daily lifting of 50-pound boxes for two years caused worsening back pain. A common mistake is a vague entry like “hurt my back at work,” which gives the carrier room to deny for lack of detail. A misconception is that fewer words are safer; a complete, honest description actually protects your claim.

Question 18: Body Part Injured, Describe the Injury

This box asks which body part you hurt and the type of injury.

Name the exact body part and the injury type, such as cut, bruise, sprain, or fracture. Marcus writes LOWER BACK and MUSCLE STRAIN AND BRUISING.

If you hurt more than one body part, list them all, because the carrier only authorizes treatment for parts you report. A common mistake is naming one body part and forgetting another that also hurts, which can block coverage for the unlisted part. A misconception is that you can add injuries later with no trouble; adding body parts after filing often requires extra medical proof.

Question 19: Where Were You First Treated, Name, Address

This box asks where you first got medical care.

Enter the name and address of the first clinic, ER, or doctor you saw. Marcus writes BANNER URGENT CARE, 2900 E THOMAS RD, PHOENIX.

If you have not been treated yet, write NOT YET TREATED and get care quickly. A common mistake is leaving this blank, which slows the carrier’s request for your records. A misconception is that you must use a company doctor; in most Arizona claims you may choose your own treating physician.

Question 20: Who Treated You for This Injury, Name, Address

This box asks for your ongoing treating provider.

Enter the name and address of the doctor managing your care. Marcus writes DR. ANITA SHAH, 3200 N CENTRAL AVE, PHOENIX.

If it is the same as your first treatment, you may repeat it. A common mistake is leaving this blank when a doctor is treating you, which delays authorization of continued care. A misconception is that listing a doctor locks you in forever; you can request a change of doctor through the ICA later.

Question 21: Lost Time From Work Due to an Accident in the Past 12 Months?

This box asks whether you lost work time from any other accident in the last year, and where it happened.

Mark YES or NO, and if YES name the state and whether it was a WORK INJURY. Marcus marks NO.

If you did lose time, answer honestly even if it feels risky. A common mistake is hiding a prior injury, which the carrier can find and use to accuse you of fraud. A misconception is that a past injury automatically blocks the new claim; it does not, but concealing it can.

Question 22: Ever Received Any Permanent Disabling Injury?

This box asks about any past permanent disabling injury.

Mark YES or NO, and if YES give the date, whether it was a work injury, and the state. Marcus marks NO.

If you have a prior permanent impairment, disclose it, because Arizona’s apportionment rules may divide responsibility fairly. A common mistake is hiding a prior disability, which can void your credibility. A misconception is that disclosing past injuries lowers your benefits; honesty protects the claim, while concealment can destroy it.

Question 23: Receiving Compensation for Any Disabling Conditions? Signature

This last box asks whether you now receive compensation for any disabling condition, from whom, how much, and why, and then requires your signature.

Mark YES or NO and complete the details if YES, then read the certification and sign and date the form. The certification states you apply for all benefits and certify, knowing it is a crime to make willful false statements, that your answers are true and complete. Marcus marks NO and signs Marcus Bell, dated 02/12/2026.

If an authorized representative signs for you, that is allowed, but the signature is REQUIRED either way. A common mistake is mailing the form unsigned, which means it is not a valid claim and the ICA cannot process it. A misconception is that the signature is a formality; it is a sworn legal statement, and false answers can be charged as fraud.

Three Filled-Out Examples Using Real Scenarios

These three filers show how different injuries flow through the same form. Each follows one worker from name to signature so you can see what real entries look like.

Scenario 1: Marcus, a warehouse worker with a sudden back injury. Marcus strains his lower back when a loaded pallet jack rolls into him on the loading dock.

Form Section	What Marcus Enters
Q1 Name / SSN / Birth	BELL, MARCUS A; 234-56-7890; 07/22/1990
Q4 Employer	VALLEY DISTRIBUTION LLC
Q9 Date / Time / Wage	02/10/2026; 9:15 AM; $21.00
Q10 Location of Accident	LOADING DOCK B, 4400 S 40TH ST, PHOENIX
Q12 Reported To	02/10/2026; SARA KIM; SHIFT LEAD
Q16 Machine or Tool	PALLET JACK, MODEL 5000
Q17 How Accident Happened	Pallet jack rolled back on dock ramp and pinned my lower back against a steel post
Q18 Body Part / Injury	LOWER BACK; MUSCLE STRAIN AND BRUISING
Q23 Signature / Date	Marcus Bell; 02/12/2026

Scenario 2: Linh, a restaurant prep cook with a gradual repetitive-strain injury. Linh develops wrist pain from years of chopping and lifting, a condition that built up slowly rather than from one event.

Form Section	What Linh Enters
Q1 Name / SSN / Birth	TRAN, LINH; 345-67-8901; 11/03/1988
Q4 Employer	SAGUARO BISTRO INC
Q9 Date / Time / Wage	01/15/2026 (first knew it was work-related); $16.75
Q10 Location of Accident	KITCHEN PREP STATION, 77 E MCDOWELL RD, MESA
Q12 Reported To	01/15/2026; OMAR HADI; KITCHEN MANAGER
Q16 Machine or Tool	CHEF KNIFE AND CUTTING STATION (repetitive use)
Q17 How Accident Happened	Daily chopping and lifting for three years caused worsening pain and numbness in my right wrist
Q18 Body Part / Injury	RIGHT WRIST; REPETITIVE STRAIN / CARPAL TUNNEL SYMPTOMS
Q23 Signature / Date	Linh Tran; 01/18/2026

Scenario 3: Diego, a construction worker injured by a third party. Diego is struck by a subcontractor’s reversing truck on a job site, so another company’s worker caused the injury.

Form Section	What Diego Enters
Q1 Name / SSN / Birth	RAMOS, DIEGO; 456-78-9012; 05/30/1983
Q4 Employer	CACTUS BUILDERS LLC
Q9 Date / Time / Wage	03/05/2026; 11:40 AM; $27.50
Q10 Location of Accident	JOB SITE, 1500 W BASELINE RD, TEMPE
Q15 Caused by Another Person	YES; driver employed by Rapid Haul Trucking
Q16 Machine or Tool	FLATBED TRUCK (reversing)
Q17 How Accident Happened	A subcontractor’s truck backed up without a spotter and struck my right leg, knocking me down
Q18 Body Part / Injury	RIGHT LEG; FRACTURED TIBIA
Q23 Signature / Date	Diego Ramos; 03/06/2026

How to File the Completed Form

Arizona gives you three ways to file Form 0407, and all of them deliver the claim to the Industrial Commission. Pick the one that fits your situation, and always keep proof that you sent it.

File online. The fastest channel is the ICA online webform, which you complete and submit in your browser at no charge. The system can email a confirmation, so save or screenshot that confirmation as your proof of filing, and expect electronic submissions to reach the Claims Division the same day.

File by mail. Print the PDF version, fill it out, sign it, and mail it to the Industrial Commission of Arizona, Claims Division, 800 W Washington Street, Phoenix, Arizona 85007. There is no filing fee. Send it by certified mail with return receipt so you have dated proof, and allow several business days for delivery and data entry.

File by fax. You may fax the completed and signed form to the Claims Division at (602) 542-3373. There is no fee. Keep the fax confirmation sheet showing the date, time, and a successful transmission as your proof of filing.

No matter which channel you choose, there is no charge to file, so no payment method is needed. The single most important thing is proof. A common misconception is that telling your employer counts as filing; it does not, because only the report reaching the ICA opens your legal claim under A.R.S. § 23-1061.

What Happens After You File

Once your form reaches the Commission, the ICA Claims Division assigns your claim an ICA claim number and notifies your employer’s insurance carrier. The carrier then has a set time to investigate and either accept or deny your claim, and it issues a written Notice of Claim Status explaining its decision. Watch your mail closely, because this notice goes to the address you wrote in Question 2.

If the carrier accepts your claim, it begins paying for authorized medical treatment and, if you miss more than the waiting period of work, it pays temporary wage-loss benefits. If the carrier denies your claim, you do not lose automatically. You have 90 days from the date on the Notice of Claim Status to file a Request for Hearing with the ICA, which sends your dispute to an administrative law judge.

A common misconception is that filing the report guarantees payment; it does not, because the carrier still investigates and can deny. The smart move is to keep copies of everything, respond to any ICA letters quickly, and never let the 90-day protest window pass without acting if you disagree with a denial. For example, Linh’s carrier first denies her wrist claim as “not work-related,” but she files a hearing request within 90 days and wins after her doctor confirms the repetitive-strain cause.

Mistakes to Avoid When Filling Out the Form

Small errors on this one page cause big delays and denials. Watch for these.

• Filing after the one-year deadline, which can permanently bar your claim under Arizona law.
• Leaving the Social Security number blank, which leaves your documents unmatched in the system.
• Writing an old or wrong mailing address, which means you miss notices and benefit checks.
• Naming a store nickname instead of the legal employer, which routes the claim to the wrong business.
• Guessing or skipping the date of injury, which corrupts your deadline and wage calculations.
• Giving a vague accident story in Question 17, which gives the carrier grounds to deny for lack of detail.
• Listing only one injured body part when several hurt, which blocks treatment for the unlisted parts.
• Hiding a prior injury in Questions 21 or 22, which can trigger a fraud accusation.
• Mailing the form unsigned, which makes it an invalid claim the ICA cannot process.
• Forgetting to keep proof of filing, which leaves you unable to show you met the deadline.
• Assuming a verbal report to your boss is a filed claim, which it is not under the statute.
• Ignoring a denial instead of filing a hearing request within 90 days, which forfeits your appeal.

Do’s and Don’ts

Do:

• Do file as soon as possible, because the one-year clock is unforgiving and early filing avoids deadline fights.
• Do answer every one of the 23 questions fully, because blanks invite delay and suspicion.
• Do use your full legal name from your SSN card, because the ICA cross-matches your records.
• Do describe the accident in clear detail in Question 17, because detail supports approval.
• Do keep a copy and proof of filing, because you may need to prove the date later.
• Do report all injured body parts, because the carrier only authorizes care for what you list.

Don’t:

• Don’t guess at the injury date, because a wrong date can wreck your deadline and benefits.
• Don’t hide a prior injury or disability, because concealment can be charged as fraud.
• Don’t use a nickname or store name, because it can misroute or stall your claim.
• Don’t mail the form without signing it, because an unsigned form is not a valid claim.
• Don’t assume telling your supervisor is enough, because only the ICA filing counts.
• Don’t ignore a denial letter, because you have just 90 days to request a hearing.

Pros and Cons of Filing on Your Own vs. With Help

Many workers file Form 0407 themselves, while others hire a workers’ compensation attorney. Each path has trade-offs.

Filing on your own:

• Pro: It costs nothing, because the form and filing channels are free.
• Pro: It is fast, because you control when you submit and avoid waiting on others.
• Pro: It keeps you in direct contact with the ICA Claims Division.
• Con: You may make field errors that delay or weaken the claim.
• Con: You handle a carrier denial or hearing without legal guidance.

Filing with an attorney’s help:

• Pro: A lawyer can frame Question 17 and medical details to strengthen the claim.
• Pro: A lawyer manages deadlines and the hearing process if the carrier denies you.
• Pro: Arizona comp attorneys typically work on a contingency fee, so you pay only if you recover.
• Con: A share of your award goes to attorney fees, which an ICA judge must approve.
• Con: Bringing in a lawyer can add steps and slow simple, clearly accepted claims.

Form 0407 vs. the Pink Form (Form 0102)

Arizona offers two ways to open a claim, and knowing the difference helps you pick the right one. The table below compares them.

Form 0407 (Worker’s Report of Injury)	Form 0102 (Worker’s and Physician’s Report)
Filled out by the injured worker alone	Filled out by the worker and the treating doctor together, often called the “pink form”
You file it directly with the ICA	The doctor’s office usually files it after your first visit
Best when you want to start the claim yourself right away	Best when a doctor sees you first and starts the claim at the clinic
Requires only your signature	Requires both worker and physician information
Both forms legally open a claim under A.R.S. § 23-1061	Both forms legally open a claim under the same statute

Either form satisfies the law, so you do not need both. If you have already seen a doctor who filed the pink Form 0102, your claim is open and you may not need to file 0407 separately. When in doubt, filing your own 0407 is a safe way to make sure the claim exists.

FAQs

Do I have to file Form 0407 within one year?

Yes. Arizona law requires you to file your claim with the ICA within one year of the date you knew or should have known the injury was work-related, or it can be barred.

Is the Worker’s Report of Injury the same as my employer’s report?

No. You file Form 0407, and your employer separately files Form 0101, the Employer’s Report of Injury, within ten days of learning about the accident.

Do I write my full legal name or my nickname in Question 1?

No nickname. Use the full legal name printed on your Social Security card so the ICA can match your records correctly.

Is the Social Security number in Question 1 really required?

Yes. The form requires it under a pre-1975 rule permitted by the federal Privacy Act, because it is the only reliable way to tell apart workers with similar names and birth dates.

Do I use today’s marital status or my status on the injury date in Question 3?

No, not today’s. Question 3 asks for your marital and dependent status as it stood on the date of injury, not the date you fill out the form.

Should I leave Question 14 blank if no one saw the accident?

No. Write NONE instead of leaving it blank, so the Commission knows you answered and did not skip the question.

Do I have to name the machine in Question 16 if no tool was involved?

No machine name needed. If no equipment caused the injury, write N/A so the box is not left empty.

Can I file Form 0407 online for free?

Yes. The ICA offers a free online webform, and you can also file free by mail or fax with no filing fee in any channel.

Does signing Form 0407 matter that much?

Yes. The signature is a sworn certification, and an unsigned form is not a valid claim, so the ICA cannot process it without your signature.

Will filing the form guarantee my benefits get paid?

No. Filing opens the claim, but the insurance carrier still investigates and issues a Notice of Claim Status accepting or denying it.

Can I add another injured body part after I file?

No, not freely. Adding a body part after filing usually requires extra medical proof, so list every injured part in Question 18 the first time.

Do I lose everything if the carrier denies my claim?

No. You have 90 days from the date on the Notice of Claim Status to file a Request for Hearing and have a judge review the denial.