Fill and Sign the Arizona Leave Form

INJURED WORKER:            DATE OF INJURY:       CARRIER CLAIM #-       SOCIAL SECURITY# *-             LEAVING ON:       RETURNING ON:                                           PHONE#-       DATE:       PHONE#-                         THE INDUSTRIAL COMMISSION OF ARIZONA CLAIMS DIVISION GAY CONRAD KRUGLICK, CHAIRMANMIKE PETCHEL, VICE CHAIRMANJEAN PIERRE ANGELCHIK, M.D. MEMBERSANDRA L. GRUNOW, MEMBERJAMES B. WHITTEN, MEMBER P.O. BOX 19070 KAREN ELLERMAN PHOENIX, ARIZONA 85005-9070 CLAIMS MANAGER(602) 542-4661FAX (602) 542-3373 REQUEST TO LEAVE THE STATE LARRY ETCHECHURY, DIRECTORTERESA HILTON, SECRETARY ICA CLAIM#: PLEASE, BEFORE MAILING MAKE SURE THAT ALL BLANKS BELOW ARE FILLED OUT COMPLETELY. THIS WILL HELP US PROCESS YOUR REQUEST MORE EFFICIENTLY. REASON FOR REQUESTING TO LEAVE THE STATE: OUT OF STATE ADDRESS ATTENDING PHYSICIAN INJURED WORKER'S SIGNATURE INJURED WORKER'S PHONE # ADDRESS CITY, STATE, ZIP CODE 'The mandatory requirement that the social security number be included informs filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section7(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 ameans 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 havesimilar 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 SPECIALSERVICES AT (602) 542-1829. (Rev. 5/00)