Arizona > Workers Comp
Petition For Rearrangement Or Readjustment Of Compensation ICA 04-0529-71 - Arizona
| Petition For Rearrangement Or Readjustment Of Compensation Form. This is a Arizona form and can be used in Workers Comp . |
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INDUSTRIAL COMMISSION OF ARIZONA IMPORTANT: This completed form must be filed at an Industrial Commission of Arizona PETITION FOR REARRANGEMENT (ICA) office. (See addresses below.) OR READJUSTMENT OF COMPENSATION Copies of the Arizona Workers Compensation Laws and Arizona Workers Compensation Practice and Procedure and information about the ICA claims and hearing process are available at the ICA offices and through the ICA web-site located at: www.ica.state.az.us Social Security No. * Injured Worker vs. Date of Injury: Defendant Employer ICA Claim No.: Ins. Carrier Claim No.: Defendant Insurance Carrier Injured Worker Carrier Requests rearrangement or readjustment of compensation for the following reasons: 1. State below all employment of injured worker within the past two years: NAME & ADDRESS OF EMPLOYER PERIOD WORKED TYPE OF TOTAL WAGES REASON FOR INCLUDING SELF-EMPLOYMENT FROM THROUGH WORK EARNED TERMINATION MO. DAY YR. / MO DAY YR A. B. C. 2. List all other income or compensation received within the last two years: RECEIVED FROM / ADDRESS TOTAL AMOUNT A. $ B. $ 3. Has the injured worker had any other accident, injury or illness since this claim was closed? YES NO If yes, explain: 4. The following physicians have examined or treated the injured worker within the past two years for the conditions listed: DOCTORS NAME ADDRESS CONDITION AND DATE OF TREATMENT A. B. I have read this Petition for Rearrangement or Readjustment of Compensation and the information contained is true and correct to the best of my knowledge. Signature of petitioner or petitioners authorized representative is REQUIRED. Date Address Telephone No. City State Zip Phoenix: Industrial Commission of Arizona Tucson Industrial Commission of Arizona Mailing address: P.O. Box 19070 Str eet Address: 800 W. Washington St reet Office: 2675 E. Broadway Phoenix, Arizona 85005-9070 Phoenix, Arizona 85007-2922 Tucson, Arizona 85716-5342 * 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 Commissions forms, prescribed under the Commissions 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 04-0529-71 (Rev. 5/02) American LegalNet, Inc. www.USCourtForms.com
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