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INDUSTRIAL COMMISSION OF ARIZONA
800 W WASHINGTON STREET
PHOENIX, ARIZONA 85007
(602) 542-4661
REQUEST FOR HEARING
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Claim Details

Social Security No. *
9/17/2019 ]
  
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Request for Hearing Details


9/17/2019 ]
9/17/2019 ]
I request that subpoenas be issued for the following witnesses to appear and testify at hearing:
(a) Name/Address
(b) Name/Address
(c) Name/Address
Copies of the Arizona Workers’ Compensation Laws and Arizona Workers’ 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
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9/17/2019 ]
  
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IMPORTANT: You will be notified of hearing date in writing by mail. You must keep the Administrative Law Judge advised of any address change.

Phoenix:
Mailing Address:

Website:
Street Address:
Industrial Commission of Arizona
P.O. Box 19070
Phoenix, Arizona 85005-9070
azica.gov
800 W. Washington Street
Phoenix, Arizona 85007-2922
Tucson:
Office:
Industrial Commission of Arizona
2675 E. Broadway
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 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 CLAIMS AT (602 542-4661).

Form ICA 0446 - Rev 6/2019

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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