INDUSTRIAL COMMISSION OF ARIZONA
                                                    800 W WASHINGTON STREET
                                                             PHOENIX, ARIZONA 85007
                                                                      (602)542-4661
                                                    WORKER’S REPORT OF INJURY
Copies of the Arizona Workers’ Compensation Laws and Arizona Workers’ 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.azica.gov  
ANSWER ALL QUESTIONS FULLY  
1.         NAME OF INJURED WORKER:
                                                                      LAST                                                          FIRST                                      M.I.
           SOCIAL SECURITY #  :*                                 BIRTH DATE:                                                   PHONE #: 
2.         ADDRESS:
                                                                                                             CITY                   STATE                                ZIP CODE 
3.         MARITAL STATUS:                   SINGLE MARRIED           DIVORCED  DEPENDENTS AT TIME OF INJURY:                                YES                           NO 
4.         EMPLOYER:                                                                                              SUPERVISOR:
5.         PHONE #:
                                                    EMPLOYER ADDRESS:                                                          CITY                                      STATE ZIP CODE 
6.         DATE HIRED:                              WHERE HIRED:                                                           OCCUPATION: 
7.         HOURS WORKED PER DAY:                                      PER WEEK:                                             HOURLY WAGE: 
8.         DID YOU RECEIVE FOOD OR LODGING IN ADDITION TO WAGE?                 YES                                         NO 
9.         DATE OF INJURY (MO/DAY/YEAR):                                        TIME OF INJURY:                                                AM                          PM 
10.        ADDRESS OR LOCATION OF ACCIDENT:
11.        DID YOU STOP WORK IMMEDIATELY?                                       WHEN DID YOU STOP? 
12.        WHEN DID YOU REPORT THE INJURY?                                 TO WHOM?                                                     TITLE: 
13.        WHEN DID YOU RETURN TO WORK?                                    REGULAR WORK                                             OTHER WORK 
14.        NAMES OF PERSONS WHO SAW THE ACCIDENT.
           1. NAME:                                          ADDRESS:                                                               PHONE #: 
           2. NAME:                                          ADDRESS:                                                               PHONE #: 
15.        WAS ACCIDENT CAUSED BY ANOTHER PERSON?                               IF SO, BY WHOM? 
16.        NAME OF MACHINE OR TOOL WHICH MAY HAVE CAUSED THE ACCIDENT:
17.        STATE HOW ACCIDENT HAPPENED:

18.        BODY PART INJURED:                                         DESCRIBE THE INJURY (CUT, BRUISE, ETC.): 
19.        WHERE WERE YOU FIRST TREATED:            NAME:                                                          ADDRESS: 
20.        WHO TREATED YOU FOR THIS INJURY:         NAME:                                                          ADDRESS: 
21.        OTHER THAN THIS INJURY, HAVE YOU LOST TIME FROM WORK DUE TO AN ACCIDENT IN THE PAST 12 MONTHS?                                      YES                         NO 
           NAME OF STATE WHERE ACCIDENT HAPPENED:                                                                              WORK INJURY:  YES                           NO 
22.        OTHER THAN THIS INJURY, HAVE YOU EVER RECEIVED ANY PERMANENT DISABLING INJURY?                                           YES        NO 
          DATE OF INJURY:                                                  WORK INJURY:                           YES          NO
          NAME OF STATE WHERE ACCIDENT HAPPENED:
23.       OTHER THAN THIS INJURY, ARE YOU RECEIVING COMPENSATION FOR ANY DISABLING CONDITIONS?                                            YES                            NO
           IF SO, FROM WHOM?  AMOUNT?  WHY?
          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 of my statements on this form are true, accurate and complete.

          Signature of injured worker or injured worker’s authorized representative is REQUIRED.                                            Date 
 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. 

          Submitter Email Address

          Employe rEmail Address:                                               Worker Email Address:
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). 
Claims IC A0407-Rev 05.15.17