How to Fill Out the Arizona ICA Request for Hearing (Form 0446) — With Examples + FAQs

The Arizona ICA Request for Hearing (Form 0446) is the document an injured worker files with the Industrial Commission of Arizona to formally protest a notice or award on a workers’ compensation claim and ask a judge to review it. You file it when you disagree with a decision your employer’s insurance company made — a denied claim, a closed claim, or a wrong benefit amount — and you want a hearing in front of an Administrative Law Judge.

Time is the enemy here. You have only 90 days from the mailing date of the notice you disagree with to file this form, and the 90-day appeal rule is strict. Miss it, and the decision becomes final — even if it was flat-out wrong. The current version of Form 0446 carries a revision date of 02/06/2026, so check the ICA forms page to confirm you have the latest copy before you write a single word on it.

Here is what you will walk away knowing:

• 📝 How to complete every box on Form 0446 the right way, line by line.
• ⏰ How the 90-day deadline works and exactly what happens if you blow past it.
• 📂 Which documents and claim details to gather before you start.
• 📬 How to file by online portal, mail, fax, or in person, with addresses and fax numbers.
• ⚖️ What happens after you file, from the Notice of Hearing to the judge’s written decision.

What Form 0446 Is and Who Must File It

Form 0446 is the official Request for Hearing used in the Arizona workers’ compensation system. It is the doorway to the appeal process. When the insurance company sends you a document that contains a protest period — most often a Notice of Claim Status or an Award — and you disagree with it, this form is how you object. Filing it moves your claim out of the Claims Division and into the hands of an Administrative Law Judge, or ALJ.

You must file this form if you are an interested party who wants to challenge a decision on a claim. The most common filer is the injured worker, also called the claimant. Employers and insurance carriers can also file, but the bulk of these forms come from hurt workers who feel the system got it wrong. You cannot have a spouse, friend, or family member file on your behalf as your representative — under the ICA hearing rules, only an Arizona-licensed lawyer can represent you.

The form exists because of Arizona’s workers’ compensation statutes in A.R.S. Title 23, Chapter 6. The agency that receives the form is the Industrial Commission of Arizona. The statute that governs the hearing referral is A.R.S. § 23-941, and the deadline that controls everything is the 90-day protest window. The penalty for ignoring that deadline is the harshest in the system: your right to a hearing disappears, and the decision you disagreed with stands forever.

This form is not the same as the Petition to Reopen (Form 0528) or the Notice of Intent investigation request (Form 1061J). The 1061J form plainly warns that if you are protesting a Notice of Claim Status or a denied claim, you must use Form 0446 instead. Grabbing the wrong form wastes precious days off your 90-day clock.

Before You Start: Documents and Information You Need

Filling out Form 0446 goes faster and cleaner when you gather your paperwork first. Rushing without these items is how people leave boxes blank or write the wrong claim number, which slows down processing. Below is a pre-filing checklist of everything to have in front of you before you open the form.

• The notice or award you are protesting. This is the single most important document, because it holds your claim number, the insurance company’s name, and the mailing date that starts your 90-day clock. Without it, you cannot fill the form out correctly.
• Your ICA claim number. The Commission files everything by this number, and a wrong or missing number can cause your form to be matched to the wrong file or held up.
• The mailing date printed on the notice. This date — not the date you received it — controls whether you are inside the 90-day window. Miss-reading it can cost you your appeal.
• Your full legal name and current mailing address. The ALJ mails every hearing notice to your address of record, and if mail does not reach you, your case can be dismissed.
• A working phone number and email address. The Commission and the ALJ use these to reach you about scheduling, and a hearing is often held by Google Meet video.
• The name of your employer at the time of injury. This identifies the correct claim and the correct insurance carrier you are disputing.
• The name of the insurance carrier or claims administrator. They are the defendants in your case and must be named so the Commission can notify them.
• A clear, written reason for your protest. You must state why you disagree, and a vague reason can delay the scheduling of your hearing.

If any item is missing, get it before you file. A missing claim number or a wrong mailing date is the kind of small error that creates big delays, and on a 90-day clock, delays are dangerous.

Where to Get the Form and How to Access It

You get Form 0446 straight from the source — the Industrial Commission of Arizona forms page. The form is free. You should never pay a third-party website for a copy, and you should never use an old printout you found in a drawer, because field labels and instructions change between revisions. The current revision is dated 02/06/2026.

You can reach the form three main ways. First, download the fillable PDF directly from the Request for Hearing Form listing on the ICA website and type your answers into it on your computer. Second, complete and file it electronically through the ICA Community portal at azicawc.force.com/claims, where you can also see your claim file in real time. Third, you can pick up a paper copy in person at the Commission’s Phoenix or Tucson office.

If you do not understand English well, the Commission posts a Spanish-language guide and will hire an interpreter for your hearings once you ask. The ICA video guide walks unrepresented workers through the hearing process and is worth watching before you file. The Commission’s Ombudsman, reachable at 602-542-4538 or help@azica.gov, can answer general questions about the process — though the Ombudsman cannot give legal advice.

A quick word on the right version. If the form has a revision date that is older than 02/06/2026, you may be holding an outdated copy. Using an old form can mean missing a field the Commission now expects, which can lead to a request for clarification and lost time. Always pull a fresh copy the day you plan to file.

Step-by-Step: How to Fill Out Form 0446 Line by Line

Form 0446 is short, but every box matters. Work through it in order, top to bottom. Write in black ink if you use a paper copy, and type your answers if you use the fillable PDF. Below is each field, what it asks, how to answer it, and the traps to avoid.

1. ICA Claim Number

What it asks in plain English. This box wants the unique number the Industrial Commission assigned to your workers’ compensation claim.

How to answer it. Copy the claim number exactly as it appears at the top of the notice or award you are protesting. Match every digit and any letters.

A specific example answer. Carlos Mendez finds the number on his Notice of Claim Status and writes 20231-456789 in the claim number box.

A nuance or edge case. If you have more than one open claim from different injuries, make sure you use the claim number for the specific injury you are protesting, not a different one.

A common mistake and its consequence. Writing the wrong claim number, or leaving it blank, can cause the Commission to match your request to the wrong file or fail to process it, which can eat into your 90-day window.

A misconception people hold. Some filers think the claim number is the same as their Social Security number or their insurance policy number. It is not. It is the ICA’s own number, printed on every notice it sends you.

2. Injured Worker / Applicant Name

What it asks in plain English. This box wants your full legal name as the person who was hurt on the job.

How to answer it. Write your first name, middle name or initial, and last name as they appear on your claim file. Keep it consistent with what the Commission already has.

A specific example answer. Maria Lopez writes Maria G. Lopez in the applicant name box.

A nuance or edge case. If you changed your name after the injury — through marriage or a court order — use the name on the existing claim and note the change so the Commission can connect the records.

A common mistake and its consequence. Using a nickname or a different spelling than your claim file can make it hard for the Commission to match your request to your claim, which slows processing.

A misconception people hold. People sometimes think the name has to match a photo ID exactly. What matters most is that it matches the name already on your ICA claim.

3. Address, Phone, and Email

What it asks in plain English. This section asks where you live and how the Commission and the judge can reach you.

How to answer it. Enter your full current mailing address, a phone number you answer, and an email address you check. Use the format the form provides — street, city, state, ZIP.

A specific example answer. Carlos Mendez writes 742 W Elm St, Mesa, AZ 85201, phone 480-555-0147, email cmendez@email.com.

A nuance or edge case. If you use a P.O. Box, that is fine for mail, but list a phone number so the ALJ’s office can reach you about video hearings on Google Meet.

A common mistake and its consequence. Listing an old address is one of the costliest errors on this form. The ALJ mails every Notice of Hearing to your address of record, and under A.A.C. R20-5-104, if you move without telling the Claims Division, the ALJ, and the defendants, your case can be dismissed.

A misconception people hold. Many people think filing a change of address with the post office is enough. It is not. You must notify the Commission directly any time your address changes during the process.

4. Employer Name

What it asks in plain English. This box wants the name of the company you worked for when you got hurt.

How to answer it. Write the full, legal business name of your employer at the time of the injury. Avoid abbreviations if you can.

A specific example answer. Janet Reeves writes Desert Sun Landscaping LLC in the employer box.

A nuance or edge case. If you worked through a staffing agency or a professional employer organization, list the employer named on your claim documents, since that is who the Commission has on file.

A common mistake and its consequence. Naming the wrong employer, or a parent company that is not on the claim, can confuse which insurance carrier gets notified and delay your hearing.

A misconception people hold. Workers sometimes think the employer box does not matter because the insurance company is the real opponent. It does matter — the employer is part of the defendants and helps the Commission confirm the correct claim.

5. Insurance Carrier / Claims Administrator Name

What it asks in plain English. This box wants the name of the insurance company or third-party administrator handling your claim.

How to answer it. Copy the carrier or administrator name exactly as it appears on the notice you are protesting.

A specific example answer. Carlos Mendez writes SCF Arizona / CopperPoint Insurance in the carrier box.

A nuance or edge case. Sometimes a separate claims administrator handles the file for the insurer. If both names appear on your notice, list both so the right party is served.

A common mistake and its consequence. Leaving this blank or guessing the name can mean the wrong company gets notified, and the actual defendant may not show up prepared, which can delay your case.

A misconception people hold. Some filers believe the Commission already knows the carrier and they can skip this box. Filling it in correctly avoids confusion and helps the Commission serve the right defendant.

6. The Document You Are Protesting

What it asks in plain English. This part asks which specific notice or award you disagree with.

How to answer it. Identify the document by its title and its date. For example, write Notice of Claim Status dated 04/15/2026 so there is no doubt which decision you are appealing.

A specific example answer. Janet Reeves writes Notice of Claim Status closing claim, dated 03/02/2026 in this section.

A nuance or edge case. If you received more than one notice, name the exact one you are protesting. Each protestable document has its own 90-day clock.

A common mistake and its consequence. Being vague — writing only “the notice” without a date or title — makes it harder for the ALJ to frame the issue, which can lead to delays or a prehearing conference just to figure out what you are appealing.

A misconception people hold. People think the ALJ will read the whole file and figure out what they mean. The judge needs you to point to the exact document and date so the issue is clear from the start.

7. Reason for the Request

What it asks in plain English. This is the heart of the form. It asks why you disagree and what you want the judge to decide. The form must be completed in its entirety, including the reason for the request.

How to answer it. State your reason in clear, plain words. Name the issue: a denied claim, a claim closed too soon, a wrong average monthly wage, an unpaid or undertreated medical condition, or a benefit you believe you are owed.

A specific example answer. Maria Lopez writes I disagree with the denial of my claim. My back injury happened at work on 02/10/2026 while lifting boxes, and I have medical records that support it.

A nuance or edge case. You can list more than one issue if your notice covers several points — for example, both the closing of your claim and the finding of no permanent disability. Spell out each one.

A common mistake and its consequence. Writing a vague reason like “I disagree” with no detail is the most common error in this box, and it can delay the scheduling of your hearing or force a prehearing conference to clarify the issues.

A misconception people hold. Filers think they must write a full legal argument here. You do not. You need a clear, honest statement of what you dispute and what you want — the evidence comes later, in discovery and at the hearing.

8. Signature and Date

What it asks in plain English. This box confirms that you are the one making the request and that the information is true.

How to answer it. Sign your name and write the date you are signing in MM/DD/YYYY format. If you use the online portal, the system captures your electronic signature.

A specific example answer. Carlos Mendez signs his name and writes 06/03/2026 in the date box.

A nuance or edge case. If a lawyer files for you, the lawyer signs and lists their State Bar information. A spouse or friend cannot sign for you, because they cannot represent you under ICA rules.

A common mistake and its consequence. An unsigned form is an incomplete form, and the Commission may not process it. If that happens close to your deadline, you could lose your right to a hearing.

A misconception people hold. Some think the date can be left blank or backdated. Use the true date you sign, because the filing date — not the signing date — is what counts against your 90-day window once the Commission receives it.

Three Filled-Out Examples Using Real Scenarios

Real cases make the form easier to picture. Below are three common situations, each following one named worker through the key sections of Form 0446. These tables show what each person actually enters.

Scenario 1: Maria Lopez Protests a Denied Claim

Maria hurt her back lifting boxes and the insurer denied her claim, saying the injury was not work-related. She has 90 days from the denial’s mailing date to fight it.

Form Section	What Maria Enters
ICA Claim Number	20261-334210
Injured Worker Name	Maria G. Lopez
Address	1180 E Pine Ave, Tempe, AZ 85281
Phone / Email	480-555-0199 / mlopez@email.com
Employer Name	Valley Warehouse Distributors Inc.
Insurance Carrier	CopperPoint Insurance
Document Protested	Notice of Claim Status (denial) dated 02/18/2026
Reason for Request	I disagree with the denial. My back injury happened at work on 02/10/2026 while lifting boxes. I have medical records supporting it.
Signature / Date	Maria G. Lopez / 03/05/2026

Scenario 2: Carlos Mendez Disputes a Closed Claim

Carlos’s claim was closed with a finding of no permanent disability, but he still has pain and limited movement. He wants a judge to review the closure.

Form Section	What Carlos Enters
ICA Claim Number	20251-456789
Injured Worker Name	Carlos R. Mendez
Address	742 W Elm St, Mesa, AZ 85201
Phone / Email	480-555-0147 / cmendez@email.com
Employer Name	Sunline Roofing Co.
Insurance Carrier	SCF Arizona / CopperPoint
Document Protested	Notice of Claim Status closing claim, no permanent disability, dated 03/02/2026
Reason for Request	I disagree with closing my claim and the finding of no permanent disability. I still have shoulder pain and limited motion, and my doctor recommends more treatment.
Signature / Date	Carlos R. Mendez / 03/20/2026

Scenario 3: Janet Reeves Challenges Her Average Monthly Wage

Janet believes the Commission set her average monthly wage too low, which shrinks every benefit check she receives. She files to correct it.

Form Section	What Janet Enters
ICA Claim Number	20261-110988
Injured Worker Name	Janet M. Reeves
Address	305 N Stone Ave, Tucson, AZ 85701
Phone / Email	520-555-0162 / jreeves@email.com
Employer Name	Desert Sun Landscaping LLC
Insurance Carrier	Zurich American Insurance
Document Protested	Notice of Average Monthly Wage dated 04/15/2026
Reason for Request	I disagree with the average monthly wage amount. It does not include my overtime and a second job. The correct figure should be higher.
Signature / Date	Janet M. Reeves / 05/01/2026

How to File the Completed Form

Once your form is complete and signed, you must file it at an Industrial Commission of Arizona office. The form is free to file — there is no filing fee. What matters is that the Commission receives it within your 90-day window, so always keep proof of filing.

Online (ICA Community portal). Log in or create an account at azicawc.force.com/claims using your ICA claim number, then upload your completed form. This is the fastest channel and lets you see your claim file in real time. There is no fee, and the portal gives you an electronic record that it accepted your upload. Save or screenshot the confirmation.

By mail. Send the signed form to the Claims Division. The Phoenix office is at 800 W Washington St, Phoenix, AZ 85007; the Tucson office is at 2675 East Broadway, Tucson, AZ 85716. There is no fee. Use certified mail with a return receipt so you have proof of the mailing date — and remember, the Commission must receive it in time, so mail it well before day 90.

By fax. You can fax the completed form to the Claims Division at 602-542-3373, which works for either office. There is no fee. Keep the fax confirmation page that shows the date, time, and a successful transmission as your proof of filing.

In person. Walk the form into the Phoenix office at 800 W Washington St (phone 602-542-4661) or the Tucson office at 2675 East Broadway (phone 520-628-5181). There is no fee. Ask the clerk to date-stamp a copy for you to keep as proof you filed on time.

Whatever channel you choose, the golden rule is the same: keep dated proof. If a dispute ever arises about whether you filed within 90 days, that proof is what protects your right to a hearing.

What Happens After You File

Once the Claims Division processes your request, it forwards your file electronically to the Administrative Law Judge Division — the hearing division — under A.R.S. § 23-941. An ALJ is then assigned to your case. The ALJ is an Arizona lawyer with at least five years of experience who schedules hearings, rules on motions, hears testimony, reviews evidence, and issues a written decision.

The ALJ issues a Notice of Hearing with the date, time, and location. The initial hearing is usually scheduled about 90 days after the hearing division receives your file, which gives both sides time to prepare. Most hearings are now held by remote video on Google Meet, and the Notice of Hearing tells you whether yours is remote or in person.

Before the hearing, both sides go through discovery — exchanging information through medical releases, depositions, and interrogatories. You are required to cooperate. You may also be sent to an independent medical examination with a doctor the insurer picks, and skipping it can get your request dismissed or your benefits suspended under A.R.S. § 23-1026.

After the last hearing, the ALJ issues a written Decision Upon Hearing, usually within 30 to 60 days of submission. If you disagree, you have 30 days from the mailing date to file a Request for Review. If you disagree with the Decision Upon Review, you have 30 days to file a Petition for Special Action with the Arizona Court of Appeals. Each deadline is firm, and missing one makes the decision final.

Mistakes to Avoid When Filling Out the Form

Small errors on Form 0446 can cost you your appeal. Watch out for these.

• Missing the 90-day deadline. Your right to a hearing vanishes and the decision becomes final and unappealable.
• Counting from the wrong date. Using the date you received the notice instead of its mailing date can push you past the real deadline.
• Writing the wrong claim number. Your request may be matched to the wrong file or not processed at all, burning days off your clock.
• Leaving the reason box vague. A reason like “I disagree” with no detail can delay your hearing or trigger a prehearing conference.
• Forgetting to sign. An unsigned form is incomplete, and the Commission may not process it.
• Listing an old address. Hearing notices go to your address of record, and missed mail can get your case dismissed.
• Naming the wrong employer or carrier. The wrong defendant may be notified, delaying your hearing.
• Not identifying the protested document. Without a title and date, the ALJ may not know what you are appealing.
• Using an outdated form version. An old revision may lack fields the Commission now expects, causing clarification delays.
• Keeping no proof of filing. Without a receipt or confirmation, you cannot prove you filed within 90 days if it is ever questioned.
• Assuming the post office handles your address change. The Commission requires direct notice, and a postal forward does not count.
• Picking the wrong form entirely. Using a Petition to Reopen or Form 1061J when you need Form 0446 wastes time you do not have.

Do’s and Don’ts

A few simple habits keep your filing clean and on time.

Do:

• Do file within 90 days of the mailing date, because the deadline is the one rule that can end your case before it starts.
• Do copy your claim number exactly, since the Commission files everything by that number.
• Do state a clear, specific reason, because a focused reason helps the ALJ schedule and frame your hearing faster.
• Do keep proof of filing, so you can defend your timely filing if it is ever questioned.
• Do update your address immediately if you move, since missed mail can get your case dismissed.
• Do download a fresh copy of the form, because revisions change fields and instructions.

Don’t:

• Don’t wait until the last day to file, because mailing delays can push receipt past your deadline.
• Don’t leave any required box blank, since an incomplete form may not be processed.
• Don’t have a family member file as your representative, because only an Arizona lawyer can represent you.
• Don’t guess the carrier or employer name, because notifying the wrong party causes delays.
• Don’t rely on the post office for address changes, since the Commission needs direct notice.
• Don’t skip the independent medical exam, because failing to attend can dismiss your request or suspend benefits.

Pros and Cons of Filing on Your Own vs. With a Lawyer

You can file Form 0446 yourself or hire an Arizona workers’ compensation lawyer. Each path has trade-offs.

Pros of filing on your own:

• No attorney fees, so you keep more of any benefits you win.
• Full control, because you decide how and when to file.
• Speed, since you do not have to wait to meet with a lawyer before the 90-day deadline.
• Simplicity for clear-cut issues, because the form itself is short.
• Direct access to help, since the Ombudsman and ICA guides support unrepresented workers.

Cons of filing on your own:

• The defendants will have a lawyer, and you face them without one.
• You must learn the laws and rules, because the ALJ holds you to the same standards as an attorney.
• Discovery is demanding, with depositions, interrogatories, and medical releases to handle.
• You carry the burden of proof, and you must gather and file your own medical evidence on time.
• One missed deadline can sink the case, with no lawyer watching the calendar for you.

FAQs

Do I have to file Form 0446 within 90 days?

Yes. You have 90 days from the mailing date of the notice or award you disagree with. Miss it, and the decision becomes final and you lose your right to a hearing.

Is there a fee to file the Request for Hearing?

No. Filing Form 0446 with the Industrial Commission of Arizona is free. There is no charge to request a hearing through any filing channel.

Can I file the form online?

Yes. You can upload it through the ICA Community portal at azicawc.force.com/claims using your claim number, which is the fastest filing channel and gives you electronic confirmation.

Do I write the date I received the notice in the protested-document box?

No. Use the mailing date printed on the notice, because the 90-day deadline runs from the mailing date, not the date you got it.

What do I put in the reason-for-request box if my claim was denied?

Yes, state it plainly — write that you disagree with the denial, name your injury, when and how it happened at work, and that you have medical support. Avoid vague wording.

Can my spouse or friend sign the form for me?

No. Only you or an Arizona-licensed lawyer can sign and file on your behalf. A spouse, family member, or friend cannot represent you.

Do I have to fill in the insurance carrier name if the ICA already has it?

Yes. Copy the carrier name from your notice anyway, because it confirms the correct defendant is served and prevents scheduling delays.

Will I get a hearing right away?

No. The initial hearing is usually scheduled about 90 days after the ALJ Division receives your file, giving both sides time to prepare.

Do I need a lawyer to file this form?

No. You can represent yourself, but the defendants will have a lawyer, and you will be held to the same laws and rules, so many workers choose to hire one.

What happens if I write the wrong claim number?

No, that is not safe — a wrong number can route your request to the wrong file or stop it from processing, costing you days off your 90-day clock.

Can I list more than one reason for my protest?

Yes. If your notice covers several points, such as a closed claim and a finding of no permanent disability, spell out each issue in the reason box.

Do I have to tell the Commission if I move during the process?

Yes. You must notify the Claims Division, the ALJ, and the defendants directly. A post office forwarding order does not count, and missed mail can get your case dismissed.

Can I withdraw my request after I file it?

Yes. If you change your mind, you can tell the ALJ in writing — by portal upload, fax, or mail — that you no longer want a hearing.

Is Form 0446 the same as a Petition to Reopen?

No. Form 0446 protests a current notice or award; the Petition to Reopen (Form 0528) is for a new or worsened condition after a claim has closed. They are different forms.