Free THE INDUSTRIAL COMMISSION OF ARIZONA - Arizona

THE INDUSTRIAL COMMISSION OF ARIZONA
CLAIMS DIVISION
BRIAN C. DELFS, CHAIRMAN JOE GOSIGER, VICE CHAIRMAN LOUIS W. LUJANO, SR., MEMBER MARCIA WEEKS, MEMBER JOHN A. MCCARTHY, JR., MEMBER LAURA L. MCGRORY, DIRECTOR TERESA HILTON, SECRETARY P.O. BOX 19070 PHOENIX, ARIZONA 85005-9070 Claims Division: (602) 542 4661 Claims Division Fax: (602) 542-3373

INJURED WORKER:

REQUEST TO LEAVE THE STATE

ICA CLAIM#: DATE OF INJURY: CARRIER CLAIM #: SOCIAL SECURITY # *:

PLEASE, BEFORE MAILING MAKE SURE THAT THE FORM IS FILLED OUT COMPLETELY INCLUDING YOUR SIGNATURE THIS WILL HELP US PROCESS YOUR REQUEST MORE EFFICIENTLY.
REASON FOR REQUESTING TO LEAVE THE STATE:

LEAVING ON:

RETURNING ON:

OUT OF STATE ADDRESS

ATTENDING PHYSICIAN

PHONE #:

PHONE #:

INJURED WORKER'S SIGNATURE
INJURED WORKER'S ADDRESS

DATE
INJURED WORKER'S TELEPHONE NUMBER

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. (Rev. 12/08)