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INDUSTRIAL COMMISSION OF ARIZONA
800 W WASHINGTON STREET
PHOENIX, ARIZONA 85007
(602) 542-4661
CLAIM FOR DEPENDENT’S BENEFITS – FATALITY
CHECK APPROPRIATE BOX:

Hide Section - INFORMATION REGARDING DECEASED: (Provide copy of certified death certificate)

INFORMATION REGARDING DECEASED: (Provide copy of certified death certificate)

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Account Name Lookup (New Window)
  

Hide Section - CLAIM FOR SPOUSAL BENEFITS: (Provide copy of marriage certificate)

CLAIM FOR SPOUSAL BENEFITS: (Provide copy of marriage certificate)

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Hide Section - CLAIM FOR DEPENDENT CHILDREN: (Provide copy of birth certificates)

CLAIM FOR DEPENDENT CHILDREN: (Provide copy of birth certificates)

List dependent children:
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Hide Section -  OTHER DEPENDENTS:

OTHER DEPENDENTS:


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To be filed at either office of the Industrial Commission:
Phoenix Office:
Industrial Commission of Arizona 800 W. Washington Street Phoenix, Arizona 85007-2922
Tucson Office:
Industrial Commission of Arizona 2675 E. Broadway

Tucson, Arizona 85716-5342

P. O. Box 19070

Phoenix, Arizona 85005-9070


* 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 SPECIAL SERVICES AT (602) 542-1829.


Claims ICA 0120-Rev 05.15.17

By signing this form electronically, I certify that I am an interested party or an authorized representative of an interested party. I further certify that I am authorized to sign this form and that all of the representations included in this form are true, accurate, and complete.

I agree


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