Forms
Select a button below to view the PDF. Forms to report a claim to the Industrial Commission are available at: www.azica.gov.
Worker’s Report Of Injury
Request For Hearing
Request To Change Doctors
Worker’s Annual Report Of Income
Request To Leave The State
Sole Proprietor / Independent Contractor
Work Exposure To MRSA
Significant Exposure Info
Work Exposure To Bodily Fluids
Report Of Significant Work Exposure
Contact
(602) 527-5808
steve.messer777@gmail.com
P.O. Box 30129 Mesa, AZ 85275