Scottsdale Arizona online Form 5020 2025

Scottsdale Arizona online Form 5020: What You Should Know

The applicant must be the employer of the applicant and that employee's employment terminated or terminated for cause in the manner in which the application will be handled by the Arizona Department of Labor, Employment Relations and Workforce Development. This application shall be completed by the person who injured the employee as defined in Section 12-4-103 or Chapter 49, Title 44 of the Arizona Revised Statutes, whichever is applicable. No additional information may be needed to complete this application. You may call us at 520/ to schedule a meeting. This application must be completed by individuals on duty. All individuals must complete the form and forward it to the address below, within 10 days of the date of injury. If your employer does not pay for your injured employee's medical insurance for 6 months, you should also file the appropriate medical insurance report to the appropriate agency. If your employer does not accept the benefits you need for your injured employee, you may file the insurance report for yourself to be paid on your behalf. A. Name, address, employer and employee information, and Social Security number if applicable. B. Date The accident was reported to the police or other law enforcement agency. C. Type of emergency, including type of vehicle involved, severity, injury to passenger (if any), injuries to the other passenger, and any additional information. D. Description Any additional information or information obtained from your insurer. E. Occupant You (or the person who injured you) or the injured employee. Employee Medical Insurance Report If you are filing this form, then your insurance is important for payment of your medical bills.  The insurance company may also need to see the police report in order to get your insurance information or to verify the information from your health insurance company. For this reason, we've included several pages with information about what each insurance company requires for the person who does not have health insurance, including what records you should have and what you will need to produce. Please read each item in this list carefully. Then read the section of the document that mentions your health insurance companies. F. Number of Employees Name, address and number of employees involved in the accident. If there is only one employee injured, write only the number of that employee. G. Company Identification Your Employer's Employer's Name (if you have more than one) and Address and Phone Number (if you do not have any) S. Insurance Information The name of the company covering the employee.

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