THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CONTACT SPECIAL SERVICES AT (602) 542-1829. INDUSTRIAL COMMISSION OF ARIZONA PETITION FOR REARRANGEMENT OR READJUSTMENT OF COMPENSATION Copies of the Arizona Workers222 Compensation Laws and Rules of Procedure and information about the ICA claims and hearing process are available at the ICA offices and through the ICA website located at: www.ica. with a link to the Arizona Workers222 Compensation Law and Rules of Procedure. Social Security No. * vs. Date of Injury: Defendant Employer ICA Claim No.: Ins. Carrier Claim No.: Defendant Insurance Carrier Injured Worker Carrier Requests rearrangement or readjustment of compensation for the following reasons: 1.State below all employment of injured worker within the past two years:NAME & ADDRESS OF EMPLOYER PERIOD WORKED TYPE OF TOTAL WAGES REASON FOR INCLUDING SELF-EMPLOYMENT FROM THROUGH WORK EARNED TERMINATION MO. DAY YR. / MO DAY YR A. B. C. 2. 4 List all other income or compensation received within the last two years: RECEIVED FROM / ADDRESS TOTAL AMOUNT A. $ B. $ 3.Has the injured worker had any other accident, injury or illness since this claim was closed?YES NO If yes, explain: 4.The following physicians have examined or treated the injured worker within the past two years for the conditions listed:DOCTOR222S NAME ADDRESS CONDITION AND DATE OF TREATMENT A. B. I have read this Petition for Rearrangement or Readjustment of Compensation and the information contained is true and correct to the best of my knowledge. Signature of petitioner or petitioner222s authorized representative is REQUIRED. Date Address Telephone No. City Zip Phoenix: Tucson Industrial Commission of Arizona Mailing address: Street Address: 800 W. Washington Street Office: 2675 E. Broadway Phoenix, Arizona 85007-2922 Tucson, Arizona 85716-5342 * 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 Section7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commission222s forms, prescribed under the Commission222s 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. State Industrial Commission of Arizona P.O. Box 19070 Phoenix, Arizona 85005-9070 American LegalNet, Inc. www.FormsWorkFlow.com