THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CONTACT CLAIMS AT (602) 542-4661. Social Security No. 001 vs. ICA Claim No. Defendant Employer Ins. Carrier Claim No. Date of Injury Defendant Insurance Carrier Person Requesting Hearing: A hearing is requested on: (Check appropriate box) Notice of Claim Status dated: or Notice, Award, Order or Decision by The Industrial Commission of Arizona dated: or A.R.S. 24723-1061(J) or Other: State reason for the request: Estimated length of hearing: (Address) (Address) Hearing requested at city or town of: I request that subpoenas be issued for the following witnesses to appear and testify at hearing: (a)/ (Name)(b)/ (Name)(c)/ (Address) Interpreter requested (Name)Specify Language: Copies of the Arizona Workers222 Compensation Laws and Arizona Workers222 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. Signature of person or the person222s authorized representative requesting hearing is REQUIRED. Date: Address Telephone No. City StateZip IMPORTANT: You will be notified of hearing date in writing by mail. You must keep the Administrative Law Judge advised of any address change. Phoenix: Industrial Commission of Arizona Tucson Industrial Commission of Arizona Mailing address: P.O. Box 19070 Office: 2675 E. Broadway Phoenix, Arizona 85005-9070 Tucson, Arizona 85716-5342 Street address: 800 W. Washington Street Phoenix, Arizona 85007-2922 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 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. American LegalNet, Inc. www.FormsWorkFlow.com