Risk Management & Safety Department – Insurance

Workers' Compensation

Injury Has Occurred:

Your supervisor must fill out THE UNIVERSITY OF ARIZONA SUPERVISOR'S REPORT OF EMPLOYEE INJURY/ILLNESS with the department within 7 calendar days. Supervisor may fax the report 621- 3706 and then mail original to Risk Management and Safety, P.O. Box 210300, campus mail. Hand deliver to 220 W. 6th Street, or U.S. Mail, P.O. Box 210300, Tucson, AZ 85721-0300.

You may go to Campus Health. If closed, you may go to, any hospital, or urgent care. Call 1-800- 837-8583 to report the injury.

A WORKER'S PHYSICIAN'S REPORT OF INJURY must be filled out at the location where you receive treatment for medical care (102 form, pink, four page carbon copies).

You fill out the top of this form.
Your physician fills out the bottom.

How Does a Claim Start?

Risk Mgmt. & Safety receives "Supervisor's Report of Employee Injury/Illness." We will enter the claim and send a copy of incident report to Arizona Department of Administration, State Risk Management, Workers' Compensation Unit.

A claim is generated for the any employee who is treated at any medical facility, hospital, Urgent Care, HMO, etc.
If you were seen at Campus Health a claim will be generated.
Call U of A Risk Management to report name and address of physician providing treatment. If our office is closed, call 602-542-2182.

Arizona Department of Administration, State Risk Management is the insurer for our workers compensation.

They will either accept or deny the claim. If claim is accepted you will be assigned a claims representative.
State Risk needs SUPERVISOR'S REPORT and MEDICAL DOCUMENTATION. Without this they can not process the claim and they will automatically deny the claim.
You may call Arizona Department of Administration, State Risk Management (602) 542-2182 to check status of a claim. You may also call our office (520-621-1790) and we will forward the call.

Handling Bills:

You must notify the physician, hospital or Urgent care where to send the bills and medical documentation.

If you receive a bill. You must call the location you receive a bill from and notify them this was an injury that was work related.

We are not able to do this for you.

Send Bills and Medical Documents To:

ARIZONA DEPARTMENT OF ADMINISTRATION
STATE RISK MANAGEMENT
WORKER'S COMPENSATION UNIT
100 N. 15TH AVE, SUITE 301
PHOENIX, AZ 85007 (602) 542-2182 FAX 602-542-1490

Early notification call 1-800-837-8583.

Report Our Policy Number

SELF INSURED (ARS§ 41-621)

If You Are Off Work:

Make sure you notify our office as soon as possible.

Make sure you give an off work slip to your supervisor. Send a copy of off work slip to U of A Risk Mgmt & Safety, attn. Belen Aranda, PO Box 210300, and Campus Mail.

Return to Work:

Your physician must release you to return to work. You must provide a return to work slip to supervisor.

Send a copy of return to work slip to U of A Risk Mgmt. & Safety.

Buy Back Program:

Fill out Green Form, only if off work for more than 7 calendar days.

Return buy back to Risk Mgmt. & Safety, attn: Belen Aranda, PO Box 210300, Campus Mail.

QUESTIONS ABOUT WORKERS COMPENSATION CALL 621-3626 BELEN ARANDA.

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