Form ICA NI "Worker's Supplemental Claim for Compensation" - Arizona

What Is Form ICA NI?

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 January 1, 2002;
  • 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;

Download a printable version of Form ICA NI by clicking the link below or browse more documents and templates provided by the Industrial Commission of Arizona.

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Download Form ICA NI "Worker's Supplemental Claim for Compensation" - Arizona

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Return to:
NAME:
Industrial Commission of Arizona - Special Fund
PO Box 19070
CLAIM #:
Phoenix, AZ 85005-9070
DATE OF INJURY:
WORKER’S SUPPLEMENTAL CLAIM FOR COMPENSATION
CLAIM FOR PERIOD
THROUGH
DO NOT SIGN, DATE AND RETURN THIS FORM BEFORE DATE SHOWN ABOVE
Have you returned to work?
Yes
No
Any self-employment?
Yes
No
If yes, answer questions in next section.
(Failure to answer these two questions will delay your benefits.)
IF YOU HAVE RETURNED TO WORK OR SELF-EMPLOYMENT THE FOLLOWING QUESTIONS MUST BE ANSWERED:
Date of return to work:
Job Title
Employer’s name and address:
Wage: $
Income from self-employment: $
Date of next medical appointment
Doctor
I make application for all benefits to which I may be entitled under the law. I certify, with full knowledge, that it is a crime to make willful, false statements to
obtain compensation and that all my statements on this form are true, accurate and complete.
Date Signed
Signature
Address:
Phone No.
To be completed by attending physician
How often are you seeing claimant?
Date last examined
Claimant’s condition on last examination:
Have you discharged claimant from treatment?
If so, give date
Have you released claimant as able to return to occupation performed at time of injury?
If so, give date able
If not, have you released claimant as able to perform any other type of employment?
Date able
State any functional employment limitations
If condition stationary and permanent functional impairment exists, give percentage and anatomical location of permanent impairment:
Comments:
Date of Signing
Attending Physician
Address:
THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CALL
(602) 542-3294.
ICA NI (Rev 1/2002)
Return to:
NAME:
Industrial Commission of Arizona - Special Fund
PO Box 19070
CLAIM #:
Phoenix, AZ 85005-9070
DATE OF INJURY:
WORKER’S SUPPLEMENTAL CLAIM FOR COMPENSATION
CLAIM FOR PERIOD
THROUGH
DO NOT SIGN, DATE AND RETURN THIS FORM BEFORE DATE SHOWN ABOVE
Have you returned to work?
Yes
No
Any self-employment?
Yes
No
If yes, answer questions in next section.
(Failure to answer these two questions will delay your benefits.)
IF YOU HAVE RETURNED TO WORK OR SELF-EMPLOYMENT THE FOLLOWING QUESTIONS MUST BE ANSWERED:
Date of return to work:
Job Title
Employer’s name and address:
Wage: $
Income from self-employment: $
Date of next medical appointment
Doctor
I make application for all benefits to which I may be entitled under the law. I certify, with full knowledge, that it is a crime to make willful, false statements to
obtain compensation and that all my statements on this form are true, accurate and complete.
Date Signed
Signature
Address:
Phone No.
To be completed by attending physician
How often are you seeing claimant?
Date last examined
Claimant’s condition on last examination:
Have you discharged claimant from treatment?
If so, give date
Have you released claimant as able to return to occupation performed at time of injury?
If so, give date able
If not, have you released claimant as able to perform any other type of employment?
Date able
State any functional employment limitations
If condition stationary and permanent functional impairment exists, give percentage and anatomical location of permanent impairment:
Comments:
Date of Signing
Attending Physician
Address:
THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CALL
(602) 542-3294.
ICA NI (Rev 1/2002)