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Justia Option Election Form for Workers' Compensation

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THE INDUSTRIAL COMMISSION OF ARIZONA

800 WEST WASHINGTON ST.

P.O. BOX 19070

PHOENIX, ARIZONA 85005-9070

OPTION ELECTION FORM
FOR
WORKERS' COMPENSATION POOLS UNDER A.R.S. § 23-961.01

Part A

1. Please state the name of the workers' compensation pool filing an initial or renewal application to self-insure under A.R.S. § 23-961.01.

2. Please select the option elected by the workers' compensation pool named in question number 1.

3. Please state the amount of the guaranty bond, bonds or securities of the United States, or letter of credit obtained by the pool.

$ which represents 125% of total outstanding accrued liability based on calculation set forth in Part B of this form (applicable only to workers' compensation pools filing a renewal application).
$

Part B

1. Please provide the following information for all workers' compensation claims processed from the pool's initial effective date of authority to self-insure through December 31, 1998:

a. Number of claims in which medical or compensation benefits are currently being paid by the pool.

b. Total incurred and reserved liability for medical benefits, and temporary and permanent compensation benefits (lifetime liability).

$

c. Total amount paid to date for medical benefits, and temporary and permanent compensation benefits through last reporting period.

$

d. Total amount incurred, but not paid, for medical benefits, and temporary and permanent compensation benefits (I b - I c).

$

2. Please provide the following information for all workers' compensation claims reported in 1999:

a. Number of claims accepted.

b. Total incurred and reserved liability for medical benefits, and temporary and permanent compensation benefits (lifetime liability).

$

c. Total amount paid to date for medical benefits, and temporary and permanent compensation benefits through last reporting period.

$

d. Total amount incurred, but not paid, for medical benefits, and temporary and permanent compensation benefits (2b - 2c).

$

3. Formula to determine 125% of the pool's total outstanding accrued liability.

a. Total amount incurred, but not paid, for medical benefits, and temporary and permanent disability benefits for all years listed in Part B (1d + 2d).

$

b. Amount of reimbursement received from reinsurance carrier or carriers.

$

c. Estimated future liability (3a - 3b).

$

d. 125% of total outstanding accrued liability (3c x 125%).

$

e. Amount of bond, United States bonds or securities, and letter of credit.

$

I, certify under penalty of perjury, that I have authority to sign the option election form, that I am the (title) of the pool and in that capacity have knowledge of the information contain in the option election form, that I have read the option election form, and verify that the representations and statements contained in the option election form, are true to the best of my knowledge, information, and belief.

Signature of Administrator

Printed or typed name of Administrator

The law requires that a workers' compensation pool obtain and maintain during all periods of self-insurance a guaranty bond, United States bonds or securities, or letter of credit in an amount equal to the greater of $200,000 or 125% of the total outstanding accrued liability as reflected in this form.

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What the Justia Option Election Form for Workers' Compensation Is

Justia Option Election Form for Workers' Compensation is a standardized election document used when an injured worker, employer, or insurer needs to record a formal choice about benefits, settlement, or dispute resolution procedures under a state's workers' compensation system. The form typically captures claimant identity, employer and insurer details, the specific election being made (for example, accepting a settlement or electing alternative dispute resolution), effective dates, and signatures. It supports administrative processing, creates a clear record of consent, and serves as an enforceable record when completed and filed according to jurisdictional rules.

Why a Clear Election Form Matters

Using the Justia Option Election Form clarifies the claimant's decision, reduces administrative disputes, and creates a written record for adjudicators. Accurate completion helps protect legal rights and ensures consistent processing by employers, insurers, and workers' compensation boards.

Why a Clear Election Form Matters

Who Typically Prepares or Signs This Form

Typical users include claimants, employer representatives, insurance adjusters, and attorneys completing elections or settlement acknowledgements.

  • Claimants filing or disputing benefit elections with a state board.
  • Employers documenting acceptance of settlement or compromise terms for employee claims.
  • Insurers and adjusters recording election outcomes for claim files and reserves.

Agencies and hearing officers rely on a completed form to schedule hearings or approve settlements in accordance with state procedures.

Primary Signer Roles and Responsibilities

Claimant

A worker or their authorized representative who elects benefits, settlement, or dispute resolution. Provide full legal name, claim number, date of injury, and signed affirmation; mismatches or omissions can delay processing or trigger requests for supplemental documentation.

Employer Representative

A company claims manager, HR official, or insurance adjuster authorized to file elections on behalf of the employer. Must include employer legal name, coverage policy number, and a signature block for an authorized signatory to validate the election.

Security and Compliance Considerations

Transport Encryption: TLS 1.2/1.3 in transit
Storage Encryption: AES-256 encryption at rest
Security Certifications: SOC 2 Type II, ISO 27001
Privacy Compliance: GDPR and CCPA compliance
Healthcare BAA: HIPAA compliant with BAA
Audit Trail: Detailed timestamps and logs

Key Risks and Penalty Categories

Filing Delays: Claim processing delayed
Monetary Penalties: Possible fines for late filings
Settlement Voided: Invalid signature risks voidance
Tax Withholding: Backup withholding 24% possible
Legal Challenge: Subject to appeal or review
I-9 Noncompliance: Separate federal penalties apply

Common Preparation Mistakes to Avoid

  • Using an outdated form version can lead to rejection and require refiling with current jurisdictional language and dates.
  • Mismatched names between identification, claim files, and filings are a frequent cause of processing delays and additional identity verification requests.
  • Failing to include the claim number, policy number, or exact injury date often prevents clerks from linking the election to the correct file.
  • Notarization or witness requirements overlooked at signing can render settlement elections unenforceable in some jurisdictions.

How Parties Use the Justia Option Election Form in Practice

The following examples show how different parties use the Justia Option Election Form in typical workers' compensation scenarios.

Case Study 1

A claimant agreed to a lump-sum compromise after mediation, recording the election to finalize benefits and close the claim.

  • Election processed within administrative timelines.
  • The completed form included claimant identification, settlement amount, effective date, notarized signature, and employer acceptance; the agency recorded the election, updated claim status, and disbursed funds without further hearings or appeals.

Case Study 2

An employer elected binding arbitration to resolve a disputed claim and recorded its option election under company counsel supervision.

  • Arbitration avoided a lengthy hearing calendar and backlog.
  • The signed form documented the agreement to arbitrate, included selection of arbitrator rules, and enabled the insurer to adjust reserves and streamline settlement payments without administrative backlog or court review.

Step-by-Step: Completing the Form

Follow these steps to complete the Justia Option Election Form accurately and reduce the chance of processing delays or rejection.

  • 01
    Gather Documents: Collect claim number, ID, employer and policy details.
  • 02
    Select Election: Mark the precise option and include effective date.
  • 03
    Sign and Witness: Sign in full; obtain notary or witnesses if required.
  • 04
    Submit Form: Send to the appropriate state agency or insurer contact.

Typical Routing and Processing Flow

Typical routing: claimant completes form, employer or insurer countersigns if needed, then the form is filed or retained per state procedures.

  • Prepare: Complete every required field accurately.
  • Authenticate: Choose appropriate signer authentication method.
  • File: Submit to agency or insurer as specified.
  • Archive: Store executed copy in both claimant and employer files.

Four Core Sections of a Professional Election Form

A professional Justia Option Election Form includes standardized headings, clear selection fields, signature blocks, and space for notarization or witness acknowledgment when required.

Header

Top section identifying the form version, jurisdiction, claimant name, claim number, employer, insurer, and the administrative office handling the filing; essential for accurate routing and file matching.

Election Options

Clearly labeled radio buttons or checkboxes for settlement, lump-sum, structured award, arbitration, or continuing benefits, with an adjacent field to specify related terms or conditions.

Effective Dates

Fields for election effective date, signature date, and any phased implementation dates; accurate dating affects entitlement and statute of limitations calculations and notice timelines to agencies.

Signature Block

Designated lines for claimant, employer, and insurer or representative signatures, printed names, titles, and dates; includes optional notary section and space for witness attestations when state law requires them.

Timing Expectations and Filing Deadlines

Common timeline expectations and filing deadlines associated with elections and settlements vary by state; confirm with the relevant workers' compensation board.

Acknowledge Immediately on Receipt by Agency:

Response windows vary; agencies typically acknowledge within 7–21 days.

Settlement Effective Date Filing Deadline:

Effective date dictates when claim closes; state rules determine finality.

Tax Reporting and Withholding Obligations:

Report settlements per IRS guidance; form obligations depend on payment type.

Appeal Periods, Deadlines and Rights:

State statutes set appeal windows; missing deadlines may forfeit rights.

Record Retention and Storage Recommendation:

Keep executed forms for at least three years, longer for tax or HIPAA matters.

Six Additional Elements to Enhance Clarity and Enforceability

Essential components improve clarity and enforceability: clear election language, identification fields, signatures, notary block, supporting attachments, and routing instructions for agencies or insurers.

Identification

Complete claimant full legal name, date of birth, Social Security number or ITIN, claim number, and contact information; mismatches can delay adjudication or trigger identity verification.

Election Details

Specify the exact election choice, related monetary amounts, structured terms if applicable, and any contingent provisions; ambiguity in the election language often causes disputes over enforcement.

Authority

Identify the signing authority and include title, organizational affiliation, and contact details for employer or insurer signatories; include documentation proving authorization when the signer is an agent or representative.

Attachments

Attach supporting documents such as bills of review, medical reports, settlement calculations, employer correspondence, and prior determinations to provide context and evidence for the election.

Notary Section

Include notary acknowledgement or witness block if state law requires it; remote online notarization may be acceptable where authorized and where identity-proofing standards are met.

Routing

Provide clear instructions for filing or service: specify agency name, mailing or electronic filing address, insurer contact, and whether the employer or claimant retains the original document after submission.

Suggested e-Filing Workflow Configuration

Configure an e-filing workflow to collect, validate, and route the Justia Option Election Form to the insurer, agency, and claimant.

Field Name and Configuration Details Configuration
Claimant Information Field and Validation Require full legal name and ID
Election Selection Input and Rules Use radio or dropdown with conditional notes
Signature Authentication Options and Levels Enable email, SMS code, or ID verification
Routing, Notifications, and Filing Destinations Notify insurer, claimant, and agency on completion

Platform and Integration Notes for eSubmission

Use an eSignature platform compatible with common formats and integrations.

  • File Formats: PDF, DOCX, or HTML accepted
  • Integrations: Works with Salesforce and NetSuite
  • Authentication: Supports SMS code and ID checks

eSignature Pricing and Capability Comparison

Below is a vendor pricing and capability overview frequently used for eSignature-enabled document workflows relevant to workers' compensation forms.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently Asked Questions and Troubleshooting

Answers to common questions about execution, e-signature legality, notarization, corrections, and filing for the Justia Option Election Form.


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