Form 4. Caption for Industrial Commission of Arizona Special Action

Attorney or Party Name Law Firm Name (if any) State Bar No. (if any) Mailing Address City, State, Zip Code Telephone Number Email Address (if required) Attorney for (party name) ARIZONA COURT OF APPEALS DIVISION [ONE OR TWO] WORKER NAME, ) Court of Appeals ) Division [One or Two] Petitioner, ) No. 1 CA-IC___-______ ) v. ) ICA Claim ) No. _____-__________ THE INDUSTRIAL COMMISSION ) OF ARIZONA, ) Carrier Claim [if applicable] ) No.______-______-WC-___ Respondent, ) ) COMPANY NAME, ) ) Respondent Employer, ) PETITION FOR SPECIAL ACTION ) - INDUSTRIAL COMMISSION INSURANCE COMPANY NAME, ) [if applicable] ) ) Respondent Carrier. ) ) )