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