Claim Submission Process

Arizona

state-AZ

Step 1	Click on the form and complete in its entirety. NOTE: Blank fields may delay our ability to service your claim.
Step 2	Print or save the form to your hard drive. Please click on the First Report of Injury form found in the Forms, Documents, and Information section of this screen.
Step 3	To submit a claim: E-mail (preferred method): This e-mail address is being protected from spambots. You need JavaScript enabled to view it Toll Free Fax #: 877-782-3292 Toll Free Phone #: 877-782-3291 Standard Mail: SUA Insurance Company P.O. Box 06110 Chicago, IL 60606-6110

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Forms, Documents and Information

For your convenience, please find the following forms, instructions, and resources:

SUA Arizona Claims Kit

Arizona Employer's Report of Industrial Injury - Form ICA 04-0101 (Rev. 7/01)
This form is required to be completed by the employer immediately following an employee injury or accident.

To Request Workers' Compensation Posting Notices and Template Stickers click here.

Claim Questions

Inquiries should be directed to: 877-782-3291

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