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Arizona Workers Supplemental Claim Form 413

Arizona Workers Supplemental Claim Form 413

Name: Arizona Workers Supplemental Claim Form 413
Brand: US Legal Forms
Price: 59.00 USD
Rating: 4.66 (454 reviews)

Category:

Arizona Workers Compensation - Special Fund

State:

Arizona

Control #:

AZ-WC-13

Format:

Instant download

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Description

Supplemental Application (For Responsible Managing Agents) Arizona Workers Supplemental Claim Form 413 is a document used to submit a supplemental claim for benefits to the Arizona Industrial Commission. This form is typically used by injured workers and their employers, or their representatives, to request weekly benefits to supplement their regular workers' compensation benefits. There are three different types of Arizona Workers Supplemental Claim Form 413: Wage Loss Claim Form, Additional Authorization for Payment Form, and Additional Request for Payment Form. The Wage Loss Claim Form is used to provide information about the injured worker's job duties, wages, and any benefits they are currently receiving. The Additional Authorization for Payment Form is used to authorize a payment for a particular service or treatment. The Additional Request for Payment Form is used to ask for additional benefits or payments related to the injured worker's wage loss or disability.

Arizona Workers Supplemental Claim Form 413 is a document used to submit a supplemental claim for benefits to the Arizona Industrial Commission. This form is typically used by injured workers and their employers, or their representatives, to request weekly benefits to supplement their regular workers' compensation benefits. There are three different types of Arizona Workers Supplemental Claim Form 413: Wage Loss Claim Form, Additional Authorization for Payment Form, and Additional Request for Payment Form. The Wage Loss Claim Form is used to provide information about the injured worker's job duties, wages, and any benefits they are currently receiving. The Additional Authorization for Payment Form is used to authorize a payment for a particular service or treatment. The Additional Request for Payment Form is used to ask for additional benefits or payments related to the injured worker's wage loss or disability.

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FAQ

The Industrial Commission of Arizona administers and enforces state laws relating to the protection of life, health, safety and welfare of Arizona's employees. This includes laws relating to workers' compensation, occupational safety and health, payment of wages, and child labor.

In Arizona, workers' comp covers all medical expenses to heal the work-related injury or illness. It can also provide some of the missed wages when injured workers need time off to recover. Coverage requirements in Arizona say you must provide workers' comp for full-time and part-time workers.

Arizona law prohibits employers from firing an injured employee strictly because they filed a workers' compensation claim, and your employer cannot prevent you from filing a claim by firing you. However, injured status doesn't protect your job, even if your employer is at fault for your injury.

Claims - Filing a Claim It is the injured worker's responsibility to file a claim within one year of the date of injury. The injured worker should also notify the employer as soon as possible that a work-related injury has occurred.

Arizona's workers' compensation statute of limitations requires an injured worker to report his or her work-related injury within 1 year from the date of injury. If the worker doesn't file a claim before the 1 year deadline, he or she may forfeit their right to receive compensation.

The surviving beneficiaries can receive a combined 67% of the worker's average monthly wage, up to a statutory maximum of $4,741 for injuries that happened in 2019. Workers' comp benefits in Arizona also include up to $5,000 in burial expenses.

Compensation is payable every 14 to 30 days, depending on the type of disability. No wage loss benefit is payable for the first 7 consecutive calendar days, if total time lost is less than 13 consecutive calendar days. This waiting period occurs only once during a claim.

More info

You will need the following information to complete the application: The entire SJDB voucher including proof of service (page 6). The employer must complete this form even if it disputes your contention that an injury or disease is related to employment, or that it occurred at all.Submitted on Accidental Injury, Critical Illness, Hospital Care, or Thermal claim online using this simple form. Learn the process for filing an auto insurance claim with Progressive. 15, Application for Authority to Transact Business in Illinois. FSA will start the application period on March 16, 2023. Mediate area shall mean the entire assigned work area (a preload work area means the number of cars a qualified employee would be loading). Search for insurance rates for auto, homeowners, Medicare Supplement (Medigap) and small group health insurance? 12(g)(6) at the request of a State agency. Mediate area shall mean the entire assigned work area (a preload work area means the number of cars a qualified employee would be loading).

Arizona Workers Supplemental Claim Form 413

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What does the Industrial Commission of Arizona do?

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How long do you have to report a work injury in Arizona?

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