Fill and Sign the Hearing Workers Compensation Form

     Social Security No. *       ICA Claim No.       Ins. Carrier Claim No.       Date of Injury                  Person Requesting Hearing:       Notice of Claim Status dated:       Notice, Award, Order or Decision by The Industrial Commission of Arizona dated:       A.R.S. §23-1061(J) Other:       State reason for the request:                   Hearing requested at city or town of:       Estimated length of hearing:                                                                                     INDUSTRIAL COMMISSION OF ARIZONA IMPORTANT: This completed form must be filed at an Industrial Commission office. (See addresses below.) REQUEST FOR HEARING VS. Injured Worker Defendant Employer Defendant Insurance Carrier A hearing is requested on: (Check appropriate box) or M O N T H / D A YE A R or MONTH/DAYEAR or 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 Rules of Procedure and information about the Industrial Commission of Arizona claims and hearingprocess are available at the Industrial Commission offices and through the ICA web-site located at: www.ica.state.az.us with a link to the Arizona Workers' Compensation Law and Rules of Procedure. Signature of person or the person's authorized representative requesting hearing is REQUIRED. Date: Address Telephone No. City State Zip 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: Industrial Commission of Arizona Tucson Industrial Commission of Arizona Mailing address: P.O. Box 19070 Office: 2675 E. Broadway Phoenix, Arizona 85005-9070 Tucson, Arizona 85716-5342 Street address: 800 W. Washington StreetPhoenix, Arizona 85007-2922 * 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 ispermitted 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 anindividual. 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 bedistinguished 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. F.- ICA ~ ~6 75 (R. 6/00)