Industrial commission of arizona request for ... - State Legal Forms 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Social Security Number of the injured worker at the top of the form. This is essential for identification purposes.
3. Fill in the ICA Claim Number and Ins. Carrier Claim Number, along with the Date of Injury. Ensure accuracy as these details are crucial for processing your request.
4. Indicate who is requesting the hearing by filling in their name and address in the designated section.
5. Select the reason for your hearing request by checking the appropriate box and providing any relevant dates.
6. State your reason for requesting a hearing clearly in the provided space to ensure your concerns are addressed.
7. Specify where you would like the hearing to take place and estimate its length.
8. List any witnesses you wish to subpoena, including their names and addresses, ensuring all information is complete.
9. Finally, sign and date the form, providing your address and telephone number before submitting it to an Industrial Commission office.

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