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REQUEST TO LEAVE THE STATE


  = Required Information

Injured Worker Details

12/1/2020 ]

PLEASE, BEFORE MAILING MAKE SURE THAT THE FORM IS FILLED OUT COMPLETELY INCLUDING YOUR SIGNATURE THIS WILL HELP US PROCESS YOUR REQUEST MORE EFFICIENTLY.

Request Details


12/1/2020 ]
12/1/2020 ]

Out of State Details

  

Attending Physician

Authentication Details

12/1/2020 ]

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* 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.


Claims ICA 0121-Rev 07.01.13
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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