ICA Form 102Worker's and Physician's Report of Injury
Issued by Industrial Commission of Arizona (ICA)
Worker's and Physician's Report of Injury (ICA Form 102) — state-prescribed clinician report used by the state workers’ comp agency.
Key facts
Clinicians fill out · Submitted to regulator · Employers file
- When it’s used
- Every known injury arising out of or in the course of employment resulting in loss of life or injury requiring medical treatment. Physician shall forthwith report the accident and injury to the employer, insurance carrier, and the commission (ARS §23-908(A),(E)).
- Who fills it out
- Treating physician of record. ARS §23-908 refers to 'physician' broadly. Arizona statute does not explicitly address NP/PA signing of ICA Form 102. NPs and PAs may practice under supervising physician per AZ Board of Medical Examiners rules.
- Who signs
- ARS §23-908 refers to 'physician' broadly. Arizona statute does not explicitly address NP/PA signing of ICA Form 102. NPs and PAs may practice under supervising physician per AZ Board of Medical Examiners rules.
- Where it goes
- Physician: forthwith (immediately) upon treating an injured employee; report filed with ICA and the employer's insurance carrier. Employer: within 10 days after receiving notice of accident. Reports at times and in form the commission prescribes (ARS §23-908).
- Electronic submission
- Status unspecified — ICA Form 102 must be filed with the commission and insurance carrier. Electronic submission capability not confirmed on ICA website; fax filing to ICA Claims Division at (602) 542-3373.
- Narrative substitution
- ICA Form 102 is the prescribed form. Commission prescribes the form and detail of reports per ARS §23-908(A). No explicit narrative substitute identified in statute.
Sources & citations
Every form we publish traces to an authoritative government source. We cite the issuing agency, the underlying statute, and the operative regulation so you can verify scope and signing authority for your own records.
Issuing agency
AZ Industrial Commission
Last verified 2026-03-27
VerifiedOpenStatute
ARS §23-908 (Physician Reporting)
Last verified 2026-03-27
VerifiedOpenForm library
ICA Claims Forms
Attribution. Researched and maintained in collaboration with the wc-hub workers’ compensation reporting project (AZ). BlueHive does not modify the underlying government PDF; the file you download is the agency original.
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