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INDUSTRIAL COMMISSION OF ARIZONA
800 W WASHINGTON STREET
PHOENIX, ARIZONA 85007
(602) 542-4661
WORKER'S REPORT OF INJURY
Copies of the Arizona Workers Compensation Laws and Arizona Worker's Compensation Practice and Procedure and Information about the Industrial Commission of Arizona claims and hearing process are available at the Industrial Commission offices and through the ICA web-site located at: www.azica.gov

ANSWER ALL QUESTIONS FULLY

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Injured Worker Details

NAME OF INJURED WORKER:
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SOCIAL SECURITY NUMBER# *:
  
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Employer's Details

  
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Occupation Details

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Injury Details

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TIME OF INJURY
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NAMES OF PERSONS WHO SAW THE ACCIDENT
Part of Body Injured Lookup (New Window)
Part of Body Injured List
Cause of Injury Lookup (New Window)
Cause of Injury List
Nature of Injury Lookup (New Window)
Nature of Injury List
  
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Treatment Details

WHERE WERE YOU FIRST TREATED:
WHO TREATED YOU FOR THIS INJURY:
  
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Other Details

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* The mandatory requirement that the social security number be included in forms field 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. This 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 identifies 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).

Claims ICA 0407-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.

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