WORKER'S REPORT OF INJURY ~ Salesforce

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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 Worker's 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 (You must complete all fields outlined in red to enable form submission)

Injured Worker Details

NAME OF INJURED WORKER:
FIRST:
LAST:
M.I:
PHONE#:
BIRTH DATE:		SOCIAL SECURITY NUMBER# *:
ADDRESS:

*City
STATE

ZIP CODE
MARITAL STATUS:		DEPENDENTS AT TIME OF INJURY:

Employer's Details

EMPLOYER

FEIN NUMBER

SUPERVISOR

PHONE#:

POLICY NO:

EMPLOYER ADDRESS

*City
STATE

ZIP CODE

Occupation Details

WHERE HIRED:	DATE HIRED:	[ 6/6/2023 ]
OCCUPATION:	HOURS WORKED PER DAY:
PER WEEK:	HOURLY WAGE
DID YOU RECEIVE FOOD OR LODGING IN ADDITION TO WAGE?

Injury Details

DATE OF INJURY(MO/DAY/YEAR):	[ 6/6/2023 ]	TIME OF INJURY
ADDRESS OR LOCATION OF ACCIDENT:
DID YOU STOP WORK IMMEDIATELY?		WHEN DID YOU STOP?
WHEN DID YOU REPORT THE INJURY?	[ 6/6/2023 ]	TO WHOM?

TITLE:
WHEN DID YOU RETURN TO WORK?	[ 6/6/2023 ]
REGULAR WORK		OTHER WORK
NAMES OF PERSONS WHO SAW THE ACCIDENT
NAME:
ADDRESS:
PHONE#:
NAME:
ADDRESS:
PHONE#:
WAS ACCIDENT CAUSED BY ANOTHER PERSON?		IF SO, BY WHOM?
NAME OF MACHINE OR TOOL WHICH MAY HAVE CAUSED THE ACCIDENT:
STATE HOW ACCIDENT HAPPENED:
BODY PART INJURED:		PART OF BODY INJURED	Part of Body Injured List
DESCRIBE THE INJURY(CUT,BRUISE,ETC.):		CAUSE OF INJURY:	Cause of Injury List
NATURE OF INJURY	Nature of Injury List

Treatment Details

WHERE WERE YOU FIRST TREATED:
NAME:
ADDRESS:
WHO TREATED YOU FOR THIS INJURY:
NAME:
ADDRESS:

Other Details

OTHER THAN THIS INJURY,HAVE YOU LOST TIME FROM WORK DUE TO AN ACCIDENT IN THE PAST 12 MONTHS?		NAME OF STATE WHERE ACCIDENT HAPPENED
WORK INJURY:
OTHER THAN THIS INJURY,HAVE YOU EVER RECEIVED ANY PERMANENT DISABLING INJURY?
DATE OF INJURY:	[ 6/6/2023 ]	WORK INJURY:

NAME OF STATE WHERE ACCIDENT HAPPENED:
OTHER THAN THIS INJURY, ARE YOU RECEIVING COMPENSATION FOR ANY DISABLING CONDITIONS?
IF SO, FROM WHOM?		AMOUNT
WHY?

SUBMITTER EMAIL ADDRESS:

EMPLOYER EMAIL ADDRESS:

WORKER EMAIL ADDRESS:

DOCUMENT TYPE FOR FILE UPLOAD

UPLOAD FILE
( Supported formats are .pdf, .png, .jpeg, .jpg, .tiff )

* The mandatory requirement that the social security number be included in forms field 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. This 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 identifies can only be distinguished by the social security number.

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).
Form ICA 0407 - Rev 6/2019

By signing this form electronically, I certify that I am an interested party or an authorized representative of an interested party. I further certify that I am authorized to sign this form and that all of the representations included in this form are true, accurate, and complete.

I agree

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