Form ICA 04-0521-87 Worker's Supplemental Claim Form - Arizona

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ICA 04-0521-87
Claimant’s Name:
WORKER’S SUPPLEMENTAL CLAIM FORM
Claim No:
Do not complete this form before________________________________ and return to
THE INDUSTRIAL COMMISSION OF ARIZONA
NO-INSURANCE SECTION
P.O. BOX 19070
PHOENIX, AZ 85005
Injury Date:
This form must be fully completed and signed by you (and your attending physician if you are presently under medical care). No person will be
ordered to work without a report by attending physician.
PAYMENT OF COMPENSATION CANNOT BE MADE UNTIL THIS CLAIM FORM IS RECEIVED. Use pen or typewriter.
THIS FORM IS FOR THE PERIOD FROM___________________________________ THROUGH____________________________________
MY GROSS EARNINGS FOR THE ABOVE PERIOD WERE: $_______________________________________________________
Name and address of Employer(s)
Total Amount Earned
Period of Employment
(Include Self - Employment)
Before Deductions
(From – Through)
IF YOU
___________________________
$ _____________________
_____________________________
HAVE
___________________________
$ _____________________
_____________________________
RETURNED
TO
Type of work _______________________________________Rate of Pay $_______________________________
WORK
Do you claim to have a loss of earnings due to this industrial injury? _____________________________________
If so, you must have such loss verified as indicated on the reverse side of the form to be eligible for compensation payment
Medical reports indicate that you were released as able to return to the same or a lighter type of employment as performed
at time of injury. Please state full and complete reasons for your failure to return to the type of employment to which you
released. ___________________________________________________________________________________________
IF YOU
___________________________________________________________________________________________________
HAVE NOT
List all employment to whom you have applied for work:
RETURNED
Name and Address
Date of
Job Position
Name of person
TO
Applied
Taking application
WORK
__________________
_____________________
_______________
___________________
__________________
_____________________
_______________
___________________
__________________
_____________________
_______________
___________________
Date of last registration with Arizona State employment Service _______________________________________________
(List any other employer and appropriate information on lower reverse side)
If you have received unemployment benefits during the above period of time, state the amount
$____________________
By this instrument I make application for all benefits to which I may be entitled under the law and I do herby certify, with full knowledge that it is
a crime to make willful, false statements to obtain compensation, that all of the above statements are true, accurate and complete.
Date of signing: ____________________________________________ Sign here:_____________________________________________________
Give address to which mail should be sent: ______________________________________________________________________Zip___________
STATEMENT BY ATTENDING PHYSICIAN
(If applicable-see above)
Have you discharged claimant and if so, when? ______________________________ Date last examined__________________________________
Claimant’s condition on last examination_____________________________________________________________________________________
Is claimant able to fully resume type of work performed at time of injury? ______________________________If so, give date able_____________
Is condition stationary? ___________________________________________________________________________________________________
Does claimant have a permanent functional impairment as a result of this industrial injury? ______________________________If so, give
percentage and anatomical location of functional impairment_____________________________________________________________________
_______________________________________________________________________________________________________________________
Signed this________________ day of _______________________ 20_____
NOTE: This report should not be completed and signed by physician
PAYMENT APPROVED_____________
prior to date indicated at top of form.
DATE APPROVED_________________
DATE PAID______________________
WARRANT NO___________________
____________________________________________________________
ATTENDING PHYSICIAN
____________________________________________________________________________________
(OVER)
ADDRESS
PHONE
ICA 04-0521-87
Claimant’s Name:
WORKER’S SUPPLEMENTAL CLAIM FORM
Claim No:
Do not complete this form before________________________________ and return to
THE INDUSTRIAL COMMISSION OF ARIZONA
NO-INSURANCE SECTION
P.O. BOX 19070
PHOENIX, AZ 85005
Injury Date:
This form must be fully completed and signed by you (and your attending physician if you are presently under medical care). No person will be
ordered to work without a report by attending physician.
PAYMENT OF COMPENSATION CANNOT BE MADE UNTIL THIS CLAIM FORM IS RECEIVED. Use pen or typewriter.
THIS FORM IS FOR THE PERIOD FROM___________________________________ THROUGH____________________________________
MY GROSS EARNINGS FOR THE ABOVE PERIOD WERE: $_______________________________________________________
Name and address of Employer(s)
Total Amount Earned
Period of Employment
(Include Self - Employment)
Before Deductions
(From – Through)
IF YOU
___________________________
$ _____________________
_____________________________
HAVE
___________________________
$ _____________________
_____________________________
RETURNED
TO
Type of work _______________________________________Rate of Pay $_______________________________
WORK
Do you claim to have a loss of earnings due to this industrial injury? _____________________________________
If so, you must have such loss verified as indicated on the reverse side of the form to be eligible for compensation payment
Medical reports indicate that you were released as able to return to the same or a lighter type of employment as performed
at time of injury. Please state full and complete reasons for your failure to return to the type of employment to which you
released. ___________________________________________________________________________________________
IF YOU
___________________________________________________________________________________________________
HAVE NOT
List all employment to whom you have applied for work:
RETURNED
Name and Address
Date of
Job Position
Name of person
TO
Applied
Taking application
WORK
__________________
_____________________
_______________
___________________
__________________
_____________________
_______________
___________________
__________________
_____________________
_______________
___________________
Date of last registration with Arizona State employment Service _______________________________________________
(List any other employer and appropriate information on lower reverse side)
If you have received unemployment benefits during the above period of time, state the amount
$____________________
By this instrument I make application for all benefits to which I may be entitled under the law and I do herby certify, with full knowledge that it is
a crime to make willful, false statements to obtain compensation, that all of the above statements are true, accurate and complete.
Date of signing: ____________________________________________ Sign here:_____________________________________________________
Give address to which mail should be sent: ______________________________________________________________________Zip___________
STATEMENT BY ATTENDING PHYSICIAN
(If applicable-see above)
Have you discharged claimant and if so, when? ______________________________ Date last examined__________________________________
Claimant’s condition on last examination_____________________________________________________________________________________
Is claimant able to fully resume type of work performed at time of injury? ______________________________If so, give date able_____________
Is condition stationary? ___________________________________________________________________________________________________
Does claimant have a permanent functional impairment as a result of this industrial injury? ______________________________If so, give
percentage and anatomical location of functional impairment_____________________________________________________________________
_______________________________________________________________________________________________________________________
Signed this________________ day of _______________________ 20_____
NOTE: This report should not be completed and signed by physician
PAYMENT APPROVED_____________
prior to date indicated at top of form.
DATE APPROVED_________________
DATE PAID______________________
WARRANT NO___________________
____________________________________________________________
ATTENDING PHYSICIAN
____________________________________________________________________________________
(OVER)
ADDRESS
PHONE
TO BE COMPLETED AND SIGNED BY EMPLOYER
(If applicable-see reverse)
Total GROSS earnings before deductions from (date) _____________________________________________________________________
Through _______________________________________________________ Amount $ ________________________________________
If there was any loss of earnings during the period, was it due to the industrial injury? __________________________________________
If not due to industrial injury, please indicate below the reason for the loss:
_______ Claimant returned to work in a position at a lower rate of pay.
_______ Lack of available work.
_______ Lack if overtime work.
_______ Medical care not related to injury.
_______ Personal, economic, or other reason (explain below)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Rate of pay for above earnings: Monthly $______________Weekly $______________Daily $______________Hourly $______________
Date of return to work or date of hire: _________________________________________________________________________________
Type of work performed: ____________________________________________________________________________________________
Working ability: ____________________________________________________________________________________________________
Describe any disability noted: _________________________________________________________________________________________
________________________________________
________________________________________________________________
Date
Name and Address of Employer
By ________________________________________________
Title
IMPORTANT INSTRUCTIONS TO THE CLAIMANT:
Where there is a loss of earnings due to the industrial injury: To expedite payment of compensation, it will be necessary that you and each
employer for whom you have worked as reported on the reverse side of this form, furnish this Commission with a signed statement indicating the
actual period worked and the total earnings for such work. If this is impossible, state reasons below. Otherwise, it will be necessary to withhold
payment of compensation until such time as this Commission is able to obtain such information verifying your earnings. Claimant’s additional
comments here: _______________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
THE INDUSTRIAL COMMISSION OF ARIZONA

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