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 a 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.  

This form is not used as a Request for Investigation pursuant to A.R.S. § 23-1061(J).  For a Request for Investigation, this form must be used: - Request For Investigation Form -

Information about the Industrial Commission of Arizona’s claims and hearing process including applicable laws and rules are available at the Industrial Commission offices and the ICA website:  www.azica.gov.

The following provisions must be met or the request will not be accepted:

1. The boiler or fired pressure vessel must be constructed in a manner which meets the standards of the Arizona Administrative Code, Boiler Rules: R20-5-404.
2. The owner, user or licensed contractor shall have on-site the Manufacturer's Data Report for the boiler and/or fired pressure vessel, and any other Manufacturer's manuals/documents pertinent to the contemplated alteration or repair.
3. Non-weld alterations or repairs shall be performed by an installer holding a current contractor's license issued pursuant to Chapter 10, Title 32, A.R.S. §32-1122, which authorizes the licensee to perform boiler or fired pressure vessel work.
4. This Inspection Request is not for welded alterations or repairs. Alteration or repair of a boiler or fired pressure vessel involving welding shall be performed by an organization accredited by the National Board of Boiler and Pressure Vessel Inspectors as stipulated in A.A.C. R20-5-404B.

This form must be completed in its entirety.  Failure to do so may cause a delay in processing. It can be submitted online or it can be submitted to ADOSH by mail, fax, or hand-delivery.

This form must be submitted by the 5th Business Day from the cleared date of the ACH Payment. Once completed, email the form to the GAO AFIS Operations Group at: [email protected].