This form may be used to request a hearing. It must be completed in its entirety including the reason for the request. The request for hearing should indicate which notice, award or order is being protested and the grounds on which the hearing is requested. Failure to state the reason for the request may cause a delay in processing.
Copies of the Arizona Workers’ Compensation Laws and Arizona Workers’ Compensation Rules 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 http://www.azica.gov/