Arizona > Workers Comp
Request To Leave The State - Arizona
| Request To Leave The State Form. This is a Arizona form and can be used in Workers Comp . |
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THE INDUSTRIAL COMMISSION OF ARIZONA CLAIMS DIVISION JEAN PIERRE ANGELCHIK, M.D., CHAIRMAN P.O. BOX 19070 NOREEN THORSEN JAMES B. WHITTEN, VICE CHAIRMAN PHOENIX, ARIZONA 85005-9070 CLAIMS MANAGER BRIAN C. DELFS, MEMBER LOUIS W. LUJANO, SR., MEMBER For Information Call: JOE GOSIGER, MEMBER (602) 542-4661 FAX (602) 542-3373 LARRY ETCHECHURY, DIRECTOR TERESA HILTON, SECRETARY INJURED WORKER: REQUEST TO ICA CLAIM#: LEAVE THE STATE 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 PROC ESS YOUR REQUEST MORE EFFICIENTLY. REASON FOR REQUESTING TO LEAVE THE STATE: LEAVING ON: RETURNING ON: OUT OF STATE ADDRESS ATTENDING PHYSICIAN PHONE #: PHONE #: D INJURED WORKERS SIGNATURE DATE INJURED WORKERS ADDRESS INJURED WORKERS 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 ection 7(a)(2)(BS) 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 numbe r. 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. 05/03) American LegalNet, Inc. www.USCourtForms.com
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