Form Claims ICA0122 "Request to Leave the State" - Arizona

What Is Form Claims ICA0122?

This is a legal form that was released by the Industrial Commission of Arizona - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2013;
  • The latest edition provided by the Industrial Commission of Arizona;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form Claims ICA0122 by clicking the link below or browse more documents and templates provided by the Industrial Commission of Arizona.

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Download Form Claims ICA0122 "Request to Leave the State" - Arizona

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REQUEST TO
INJURED WORKER (First, Last):
LEAVE THE STATE
ICA CLAIM#:
DATE OF INJURY:
CARRIER CLAIM #:
SOCIAL SECURITY
#
PLEASE, BEFORE MAILING MAKE SURE THAT THE FORM IS FILLED OUT COMPLETELY INCLUDING YOUR
SIGNATURE THIS WILL HELP US PROCESS YOUR REQUEST MORE EFFICIENTLY.
REASON FOR REQUESTING TO LEAVE THE STATE:
RETURNING ON:
LEAVING ON:
ATTENDING PHYSICIAN
OUT OF STATE ADDRESS
Physician Name
Address
Address
Zip Code
State
City
State
Zip Code
City
PHONE #:
PHONE #:
DATE
INJURED WORKER’S SIGNATURE
Submitter Email Address
INJURED WORKER Phone #
INJURED WORKER Address
City
State
Zip Code
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 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 an individual. 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 be distinguished by the social security number.
Claims ICA 0122-Rev 07.01.13
REQUEST TO
INJURED WORKER (First, Last):
LEAVE THE STATE
ICA CLAIM#:
DATE OF INJURY:
CARRIER CLAIM #:
SOCIAL SECURITY
#
PLEASE, BEFORE MAILING MAKE SURE THAT THE FORM IS FILLED OUT COMPLETELY INCLUDING YOUR
SIGNATURE THIS WILL HELP US PROCESS YOUR REQUEST MORE EFFICIENTLY.
REASON FOR REQUESTING TO LEAVE THE STATE:
RETURNING ON:
LEAVING ON:
ATTENDING PHYSICIAN
OUT OF STATE ADDRESS
Physician Name
Address
Address
Zip Code
State
City
State
Zip Code
City
PHONE #:
PHONE #:
DATE
INJURED WORKER’S SIGNATURE
Submitter Email Address
INJURED WORKER Phone #
INJURED WORKER Address
City
State
Zip Code
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 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 an individual. 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 be distinguished by the social security number.
Claims ICA 0122-Rev 07.01.13