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.