Petition for Rearrangement for Workers' Compensation - Arizona 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Social Security Number of the injured worker at the top of the form. This is essential for identification purposes.
3. Fill in the Date of Injury and ICA Claim Number, ensuring accuracy as these details are crucial for processing your petition.
4. In Section 1, list all employment of the injured worker over the past two years. Include employer names, addresses, periods worked, type of work, total wages earned, and reasons for termination.
5. Section 2 requires you to list any other income or compensation received in the last two years. Provide details on sources and total amounts.
6. Answer whether there have been any other accidents or injuries since your claim was closed in Section 3.
7. In Section 4, document any physicians who have treated the injured worker in the past two years. Include their names, addresses, and conditions treated.
8. Finally, ensure that you sign and date the petition at the bottom before submitting it to an Industrial Commission office.

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