Arizona Petition For Rearrangement Or Readjustment of Compensation
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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 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.

Social Security No. ∗
Injured Worker
vs.

Date of Injury:
Defendant Employer

ICA Claim No.:
Ins. Carrier Claim No.:

Defendant Insurance Carrier
Injured Worker

1.

Carrier

Requests rearrangement or readjustment of compensation for the following reasons:

State below all employment of injured worker within the past two years:
NAME & ADDRESS OF EMPLOYER
PERIOD WORKED
INCLUDING SELF-EMPLOYMENT

FROM
MO.

DAY

TYPE OF

TOTAL WAGES

REASON FOR

WORK

EARNED

TERMINATION

THROUGH
YR.