Form Claims ICA 0123 Notice of Professional Employer Agreement - Arizona

Form Claims ICA0123 is a Industrial Commission of Arizona form also known as the "Notice Of Professional Employer Agreement". The latest edition of the form was released in August 1, 2016 and is available for digital filing.

Download an up-to-date Form Claims ICA0123 in PDF-format down below or look it up on the Industrial Commission of Arizona Forms website.

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NOTICE OF PROFESSIONAL EMPLOYER AGREEMENT
The undersigned Professional Employer Organization ("PEO") hereby serves notice to its
Workers' Compensation Insurance Carrier and The Industrial Commission of Arizona that it has
(Client Employer)
entered into a Professional Emplo yer Agreement with
,
referred to as "client employer" in this Notice. The following information is provided with respect
to that Agreement and client employer:
1. Full legal name of client employer, including all other names ("aka's") under which the client
employer operates.
2. FEIN # of client employer.
3. Addresses of all locations of client employer .
Location 1
Location 2
4. For each location of client employer, are all employees covered (leased) under the PEO
agreement? Answering "yes" means all employees at a particular location are covered
(leased) employees under the PEO agreement. Answering "no" means some or all employees
at a particular location are not covered (not leased) employees under the PEO agreement
(attach separate paper for additional locations).
Location 1
Yes:
No:
Location 2 Yes:
No:
5. If you answered "no" to Question no. 4 for any location listed, state the policy number and
name of the workers' compensation insurance carrier (not TPA or servicing agent of carrier)
providing coverage to the non-leased employees of the client employer.
Date
Printed Name of PEO
Authorized Signature
Printed Name and Title of Person Signing
Email Address of Person Signing
A PEO is required to file this Notice with the PEO's Workers' Compensation Insurance Carrier and The Industrial
Commission of Arizona when a PEO enters into a Professional Employer Agreement with a client in Arizona. When
the Agreement is terminated, the PEO shall immediately notify its Workers' Compensation Insurance Carrier and The
Industrial Commission of Arizona. A.R.S. § 23-901.08. This Notice may be Submitted online or faxed to The
Industrial Commission of Arizona c/o Insurance Supervisor at (602) 542-3373.
The Industrial Commission of Arizona complies with the Americans with Disabilities Act of 1990. If you need this
Notice in alternative format, contact Claims at (602) 542-4661.
Claims ICA 0123-Rev 08.01.16
NOTICE OF PROFESSIONAL EMPLOYER AGREEMENT
The undersigned Professional Employer Organization ("PEO") hereby serves notice to its
Workers' Compensation Insurance Carrier and The Industrial Commission of Arizona that it has
(Client Employer)
entered into a Professional Emplo yer Agreement with
,
referred to as "client employer" in this Notice. The following information is provided with respect
to that Agreement and client employer:
1. Full legal name of client employer, including all other names ("aka's") under which the client
employer operates.
2. FEIN # of client employer.
3. Addresses of all locations of client employer .
Location 1
Location 2
4. For each location of client employer, are all employees covered (leased) under the PEO
agreement? Answering "yes" means all employees at a particular location are covered
(leased) employees under the PEO agreement. Answering "no" means some or all employees
at a particular location are not covered (not leased) employees under the PEO agreement
(attach separate paper for additional locations).
Location 1
Yes:
No:
Location 2 Yes:
No:
5. If you answered "no" to Question no. 4 for any location listed, state the policy number and
name of the workers' compensation insurance carrier (not TPA or servicing agent of carrier)
providing coverage to the non-leased employees of the client employer.
Date
Printed Name of PEO
Authorized Signature
Printed Name and Title of Person Signing
Email Address of Person Signing
A PEO is required to file this Notice with the PEO's Workers' Compensation Insurance Carrier and The Industrial
Commission of Arizona when a PEO enters into a Professional Employer Agreement with a client in Arizona. When
the Agreement is terminated, the PEO shall immediately notify its Workers' Compensation Insurance Carrier and The
Industrial Commission of Arizona. A.R.S. § 23-901.08. This Notice may be Submitted online or faxed to The
Industrial Commission of Arizona c/o Insurance Supervisor at (602) 542-3373.
The Industrial Commission of Arizona complies with the Americans with Disabilities Act of 1990. If you need this
Notice in alternative format, contact Claims at (602) 542-4661.
Claims ICA 0123-Rev 08.01.16

Download Form Claims ICA 0123 Notice of Professional Employer Agreement - Arizona

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