INDUSTRIAL COMMISSION OF ARIZONA

PETITION FOR REARRANGEMENT
OR READJUSTMENT OF COMPENSATION

Copies of the Arizona Worker's Compensation Laws and Arizona Worker's Compensation Practice and Procedure and Information about the ICA claims and hearing process are available at the ICA offices and through the ICA website located at: www.azica.gov with a link to the Arizona Workers Compensation Law and Rules of Procedure.

  






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12/14/2019 ]




( Supported formats are .pdf, .png, .jpeg, .jpg, .tiff )  
Phoenix:
Industrial Commission of Arizona
P.O. Box 19070
Street Address:
800 W. Washington Street
Phoenix, Arizona 85007-2922
Tucson
Office:
Industrial Commission of Arizona
2675 E. Broadway
Tucson, Arizona 85716-5342
Mailing Address
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.


Form ICA 0529 - 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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