Fill and Sign the Petition for Rearrangement for Workers Compensation Arizona Form

DOCTOR'S NAME ADDRESS CONDITION AND DATE OF TREATMENT A.            B.                  Social Security No. *       Date of Injury:       ICA Claim No.:       Ins. Carrier Claim No.:                                                                                                                                                                                                                                                                                                                                                   INDUSTRIAL COMMISSION OF ARIZONA IMPORTANT: This completed form must be filed at an Industrial Commission of Arizona(ICA) office. (See addresses below.) PETITION FOR REARRANGEMENT OR READJUSTMENT OF COMPENSATION Copies of the Arizona Workers' Compensation Laws and Rules of Procedure and information about the ICA claims and hearing process are available at the ICA officesand 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. VS. Injured Worker Defendant Employer Defendant Insurance Carrier Injured Worker Carrier Requests rearrangement or readjustment of compensation for the following reasons:1. State below all employment of injured worker with n the past two years: NAME & ADDRESS OF EMPLOYER INCLUDING SELF-EMPLOYMENT PERIOD WORKED TYPE OF TOTAL WAGES REASON FOR FROM THROUGH WORK EARNED TERMINATION MO DAY YR I MO DAY YR A- B. C. 2. List all other income or compensation received within the last two years: RECEIVED FROM / ADDRESS TOTAL AMOUNT A. $ B. $ 3. Has the injured worker had any other accident, injury or illness since this claim was closed? YES NO If yes, explain: 4. The following physicians have examined or treated the injured worker within the past two years for the conditions listed: I have read this Petition for Rearrangement or Readjustment of Compensation and the information contained is true and correct to the best of my knowledge. Signature of petitioner or petitioner's authorized representative is REQUIRED. Date Address Telephone No. City State Zip Phoenix: Industrial Commission of Arizona Tucson Mailing address: P.O. Box 19070 Street Address: 800 W. Washington StreetPhoenix, Arizona 85007-2922 Office: Phoenix, Arizona 85005-9070 Industrial Commission of Arizona2675 E. BroadwayTucson, 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 Section7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commission's forms, prescribed under he 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 thelarge 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 SPECIALSERVICES AT (602) 542-1829. Form ICA 04-0529-71 (Rev. 6/00)