WORKER’S REPORT OF INJURY
MAIL TO: Industrial Commission of Arizona, P.O. Box 19070, Phoenix, AZ. 85005-9070
Do not attach form to email; mail in envelope to address above or FAX to 602-542-3373.
Copies of the Arizona Workers’ Compensation Laws and Arizona Workers’ Compensation Practice and Procedure and information about the Industrial Commission of Arizona claims and
hearing process are available at the Industrial Commission offices and through the ICA web-site located at: www.ica.state.az.us
ANSWER ALL QUESTIONS FULLY (Use the back of this form to indicate any further information.)
NAME OF INJURED WORKER:
SOCIAL SECURITY # *:
EMPLOYER’S FULL NAME:
DEPENDENTS AT TIME OF INJURY:
HOURS WORKED PER DAY:
DID YOU RECEIVE FOOD OR LODGING IN ADDITION TO WAGE?