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.
Claims ICA 0446-Rev 05.01.02
Social Security No.
∗
Last Name
vs.
ICA Cl
aim No.
Defendant Employer Ins. Carrier Claim No.
Date of Injury
Defendant Insurance Carrier
Person Requesting Hearing:
A hearing is requested on: (Check appropriate box)
DD / MM / YYYY
Notice of Claim Status dated:
or
DD / MM / YYYY
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:
Estimated length of hearing:
(Address)
(Address)
Hearing requested at city or town of:
I request that s
ubpoenas be issued for the following witnesses to appear and testify at hearing:
(a)
/
(
Name)
(b)
/
(
N
ame)
(c)
/
(Address)
Interpreter requested
(Name)
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.azica.gov
Signature of person or the person’s authorized representative requesting hearing is REQUIRED.
Date:
Address
Telephone No.
City State Zip
IMPORTANT:
You will be notified of hearing date in writing by mail. You must keep the Administrative Law Judge advised of any address change.
Phoenix: Industrial Commission of Arizona Tucson Industrial Commission of Arizona
Mailing address: P.O. Box 19070 Office: 2675 E. Broadway
Phoenix, Arizona 85005-9070 Tucson, Arizona 85716-5342
Street address: 800 W. Washington Street
Phoenix, Arizona 85007-2922
The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial C
ommission 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.
First Name
MI
Website
azica.gov
INDUSTRIAL COMMISSION OF ARIZONA
800 W WASHINGTON STREET
PHOENIX, ARIZONA 85007
(602) 542-4661
REQUEST FOR HEARING
Email Address
