Skip to main content
Search
news-default.jpeg

Quorum Notice for Flagstaff October 12 and 13, 2016

… QUORUM NOTICE THE INDUSTRIAL COMMISSION OF ARIZONA Notice is hereby given to … Dimas, Commission Secretary … Quorum Notice for Flagstaff October 12 and 13, 2016 …
Know more

Spec Inspector Renewal App 2022

… RESPONSIBILITY TO RETRIEVE THE ARIZONA COMMISSION CARD AND RETURN IT TO THE ADDRESS … BELOW WHEN EMPLOYMENT IS TERMINATED. Request for renewal of Arizona Commission as Special …
Know more

Request for Investigation Pursuant to A.R.S. § 23-1061(J) Form

Request for Investigation Pursuant to A.R.S. § 23-1061(J) Form

Instructions

This form may be used by an injured worker to request the Administrative Law Judge (“ALJ”) Division review the claim and conduct an investigation regarding any benefit the injured worker is entitled to that has been denied. Examples include denied medical or disability benefits. If, after review and investigation, the ALJ Division determines that a hearing is required, the matter will be assigned to a hearing judge and a hearing will be scheduled. 

If you are protesting a notice, award, order, or are seeking penalty benefits pursuant to A.R.S. § 23-1061(M), do not use this form.  Use the Request for Hearing Form instead: - Request For Hearing 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

E-sign Electronic Submission Form

Request for Investigation Pursuant to A.R.S. § 23-1061(J) Form

Printable Form

news-default.jpeg

AZ Medical Data Report for Service Year 2014 now available

… AZ Medical Data Report for Service Year 2014 now available …
Know more

ADOSH Training Request Form

… This form can be submitted online or it can be … information, contact ADOSH toll free at (855) 268-5251 or (602) 542-5795 (Phoenix) or (520) …
Know more

Director's Office - Arizona Physicians' Fee Schedule - Sign In for Access

… - Arizona Physicians' Fee Schedule - Sign In for Access …
Know more

Offer and Acceptance

… Offer and Acceptance Industrial Commission of Arizona SOLICITATION NO.: PAGE 1 … St. OFFFEROR: OF 1 Phoenix, AZ 85007 SPO Form 203 – Offer and Acceptance (rev 10-2013) …
Know more

Petition for Rearrangement Form

Petition for Rearrangement Form

Instructions

An interested party or authorized representative may file a Petition for Rearrangement or Readjustment of Compensation if a qualifying change in earning capacity or condition has occurred since the last loss of earning capacity determination was made.  The burden of proof to establish the change rests with the filing party.  This form may be used to file a Petition for Rearrangement or Readjustment of Compensation.  It must be completed in its entirety.  Failure to do so may cause a delay in processing.

E-sign Electronic Submission Form

Petition for Rearrangement Form

Printable Form

AZ Seal

Quorum Notice for May 13, 2024

… QUORUM NOTICE THE INDUSTRIAL COMMISSION OF ARIZONA Notice is hereby given to … Dimas, Commission Secretary … Quorum Notice for May 13, 2024 …
Know more

W-9 Nov 2025

… … 2025 W9 form for the State of Arizona Industrial Commission … W-9 Nov 2025 …
Know more