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 18 State Forms found

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PETITION FOR REARRANGEMENT OR READJUSTMENT OF COMPENSATION

 Claims ICA 0529 Rev 06.01.00

WORKER’S ANNUAL REPORT OF INCOME

 Claims ICM 0110A Rev 06.01.15

Recommended Average Monthly Wage Calculation of Carrier

 Form ICA 0108 Rev 6/2019

UNPAID WAGE CLAIM

 Labor ICA 3303 Revised February 2022

Minimum Wage Claim Form

 Labor ICA 3325 Revised February 2022

INSURANCE CARRIER QUARTERLY ADMINISTRATIVE AND SPECIAL FUND TAX FORM #201 FOR 2020

 ACCOUNTING ICA 6601 Rev 12.15.19

REPORT OF ANNUAL WORKERS’ COMPENSATION ADMINISTRATIVE FUND & SPECIAL FUNDS PREMIUM TAX FORM 200

 ACCOUNTING ICA 6604 REV 12.5.2022

ADMINISTRATIVE AND SPECIAL FUND TAX FORM 101 FOR 2020

 ACCOUNTING ICA 6605 REV 12.05.19

SELF-INSURED HOSPITAL REPORT FOR 2020

 ACCOUNTING ICA 6613 REV 12.5.20

SELF-INSURED MEDICAL REPORT FOR 2020

 ACCOUNTING ICA 6609 REV 12.5.20

SELF-INSURED PAYROLL REPORT FOR 2020

 ACCOUNTING ICA 6608 REV 12.5.20

SELF-INSURED INJURY REPORT FOR 2020

 ACCOUNTING ICA 6611 REV 12.5.20

Automated Clearing House (ACH) Payment Reversal Form

 GAO PM-ACH1 09/2022

State of Arizona Substitute W-9: Request for Taxpayer Identification Number and Certification

 GAO-W-9 (10/2019)

NOTICE OF PERMANENT COMPENSATION PAYMENT PLAN

 ICA 04-111-84 (Rev. 94)
Disclaimer: These forms may not be the most recent version. Arizona may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.
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