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Arizona Rejection of Workers Compensation Form

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Arizona Rejection of Workers Compensation Form

FED2210

The Arizona Rejection of Workers' Compensation Form should be signed by all employees who reject the terms of the Arizona Workers’ Compensation Law. Employees must provide their addresses, social security numbers, policy numbers, and relationship to the employer along with their signatures. Employees must complete this form in order to lawfully reject the law.

Employers must file the Employee’s Notice of Rejection of Terms of the Arizona Workers’ Compensation Law form with the SCF Arizona within five days of receipt of the notice from the employee. The employer may also wish to retain a copy of the notice for his or her own records.

This package contains 25 Employee’s Notice of Rejection of Terms of the Arizona Workers’ Compensation Law notices that are fully compliant with all Arizona state laws. Employers should make these forms available to their employees in the event that the employees wish to reject the terms of the Arizona Workers’ Compensation law.

Product Specifications:

  • This form is 8.5" x 11"
  • 25 Sheets/Package

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$14.95

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Questions? Call a compliance specialist at 800-745-9970