Request To Leave The State {ICA 0122} | Pdf Fpdf Docx | Arizona

 Arizona   Workers Comp 
Request To Leave The State {ICA 0122} | Pdf Fpdf Docx | Arizona

Last updated: 11/25/2025

Request To Leave The State {ICA 0122}

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Description

ICA 0122 - REQUEST TO LEAVE THE STATE. This form is issued by the Industrial Commission of Arizona (ICA) for injured workers who wish to travel or temporarily reside outside Arizona while receiving workers’ compensation benefits. The form requires details such as the worker’s claim number, date of injury, destination address, attending physician information, and travel dates. It also asks for the reason for leaving the state and must include the injured worker’s signature for authorization. www.FormsWorkflow.com

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