Free BEFORE THE INDUSTRIAL COMMISSION OF ARIZONA_ - Arizona

INDUSTRIAL COMMISSION OF ARIZONA
IMPORTANT: This completed form must be filed at an Industrial Commission office. (See addresses below.)

REQUEST FOR HEARING
Social Security No. Injured Worker vs. Defendant Employer ICA Claim No. Ins. Carrier Claim No. Date of Injury Defendant Insurance Carrier

Person Requesting Hearing:
A hearing is requested on: (Check appropriate box)

Notice of Claim Status dated: MONTH/DAY/YEAR or Notice, Award, Order or Decision by The Industrial Commission of Arizona dated: or A.R.S. §23-1061(J) or Other:
State reason for the request:

MONTH/DAY/YEAR

Hearing requested at city or town of: I request that subpoenas be issued for the following witnesses to appear and testify at hearing:

Estimated length of hearing:

(a)
(Name)

/
(Address)

(b)
(Name)

/
(Address)

(c)
(Name)

/
(Address)

Interpreter requested

Specify Language:

Copies of the Arizona Workers' Compensation Laws and Arizona Workers' Compensation Practice and Procedure and information about the Industrial Commission of Arizona claims and hearing process are available at the Industrial Commission offices and through the ICA web-site located at: www.ica.state.az.us

Signature of person or the person's authorized representative requesting hearing is REQUIRED.

Date:

(Address of Injured Worker Only)

Telephone No.

City

State

Zip

IMPORTANT:
Phoenix: Mailing address:

You will be notified of hearing date in writing by mail. You must keep the Administrative Law Judge advised of any address change.
Industrial Commission of Arizona P.O. Box 19070 Phoenix, Arizona 85005-9070 800 W. Washington Street Phoenix, Arizona 85007-2922 Tucson Office: Industrial Commission of Arizona 2675 E. Broadway Tucson, Arizona 85716-5342

Street address:

The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commission's forms, prescribed under the Commission's Rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number.
THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CONTACT CLAIMS AT (602) 542-4661.
Form ICA 04-0446-75 (Rev. 5/02)