Arizona Worker's Report of Injury
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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.)
1.

NAME OF INJURED WORKER:
LAST

BIRTH DATE:

SOCIAL SECURITY # *:
2.

FIRST

PHONE #:

M.I.

(

)

ADDRESS:
CITY

3.

MARITAL STATUS:

SINGLE

4.

EMPLOYER’S  FULL  NAME:

5.

ADDRESS:

MARRIED

DIVORCED

STATE

ZIP CODE

DEPENDENTS AT TIME OF INJURY:

YES

NO

PHONE #:
CITY

6.

DATE HIRED:

7.

HOURS WORKED PER DAY:

8.

DID YOU RECEIVE FOOD OR LODGING IN ADDITION TO WAGE?

STATE