Request To Leave The State {ICA 0122}

REQUEST TO LEAVE THE STATE PLEASE, BEFORE MAILING MAKE SURE THAT THE FORM IS FILLED OUT COMPLETELY INCLUDING YOUR SIGNATURE THIS WILL HELP US PROCESS YOUR REQUEST MORE EFFICIENTLY. REASON FOR REQUESTING TO LEAVE THE STATE: LEAVING ON: RETURNING ON: OUT OF STATE ADDRESS ATTENDING PHYSICIAN PHONE #: PHONE #: 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 e 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. INJURED WORKER:ICA CLAIM#: DATE OF INJURY: CARRIER CLAIM #: SOCIAL SECURITY # American LegalNet, Inc. www.FormsWorkFlow.com