Last updated on Feb 20, 2026
AZ-113-WC free printable template
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See addresses below. The form must be accompanied by a current medical report supporting the reopening of the claim. PETITION TO REOPEN BASED ON NEW ADDITIONAL OR PREVIOUSLY UNDISCOVERED DISABILITY OR CONDITION Copies of the Arizona Workers Compensation Laws and Rules of Procedure and information about the ICA claims and hearing process are available at the ICA offices and through the ICA web-site located at www. Ica.state. az. us with a link to the Arizona Workers Compensation Law and Rules of...Procedure. Social Security No. Injured Worker VS. Date of Injury ICA Claim No. Defendant Employer Ins. Carrier Claim No. Defendant Insurance Carrier Reopening is requested based on the new additional or previously undiscovered disability or condition listed below related to this claim Check one of the following Attached is a medical report to support this Petition to Reopen. or Dr. INDUSTRIAL COMMISSION OF ARIZONA IMPORTANT This completed form must be filed at an Industrial Commission of Arizona...ICA office. will submit a report to support this Petition to Reopen* The following physicians have examined or treated me within the past two years for the conditions listed ADDRESS DOCTOR S NAME CONDITION AND DATE OF TREATMENT A. B. I have worked for the following employers within the past two years. NAME JOB DESCRIPTION I have read this Petition to Reopen and the information contained is true and correct to the best of my knowledge. Signature of person or the person s authorized representative...requesting reopening is REQUIRED. Dat e Address Telephone No* Cit y State Phoenix Mailing address Zip Industrial Commission of Arizona P. O. Box 19070 Street Address Phoenix Arizona 85005-9070 Tucson Office 800 W* Washington Street 2675 E* Broadway Tucson Arizona 85716-5342 The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7 a 2 B of the Federal...Privacy Act of 1974 because the Commission s forms prescribed under the Commission s Rules in existence prior to January 1 1975 required disclosure of the social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual* The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates and whose identities can only be distinguished by the...social security number. MEDICAL AUTHORIZATION By this medical authorization or reproduction I authorize and request each physician and person in the medical or related fields and each hospital clinic establishment or place rendering me any medical or related service to allow The Industrial Commission of Arizona or its authorized representative my employer or its insurance carrier and each person and physician appointed by them to have examine and/or copy any and all information records and...X-rays regarding my physical condition and treatment.
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What is AZ-113-WC
The AZ-113-WC is a form used in Arizona for documenting a worker's compensation claim.
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Who needs AZ-113-WC?
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AZ-113-WC is needed by:
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Employees filing a workers' compensation claim
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Employers managing workers' compensation cases
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Insurance adjusters processing claims
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Medical professionals providing treatment for injured workers
How to fill out the AZ-113-WC form effectively
What is the AZ-113-WC form and why is it important?
The AZ-113-WC form is a critical document in the Arizona Workers' Compensation process. It serves as a formal request to reopen a workers' compensation claim. Understanding its purpose is essential for those who have been affected by workplace injuries and wish to ensure their rights are protected.
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Designed to facilitate the reopening of previously filed claims.
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Plays a vital role in determining eligibility for continued benefits.
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Any individual whose workers' compensation claim requires further action due to ongoing medical issues.
What personal information is required?
Submitting the AZ-113-WC form requires accurate personal information. Key details include your Social Security Number, the date of your injury, and your ICA (Industrial Commission of Arizona) Claim Number. Providing these specifics is crucial for the processing of your claim.
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Used to uniquely identify your submitted claim.
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Must reflect the actual day the workplace injury occurred.
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This helps track your existing claim in the system.
What medical documentation is needed?
To support your submission of the AZ-113-WC form, certain medical documentation is necessary. These records substantiate the conditions that lead you to request the reopening of your claim and ensure that the reviewing authority has all relevant information.
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Detailed reports outlining your medical status and treatment history.
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Documentation showing that ongoing treatment is related to the original injury.
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Includes doctor's notes, treatment plans, and diagnostic tests.
How to fill out the AZ-113-WC form: A step-by-step guide
Filling out the AZ-113-WC form might seem overwhelming, but following a step-by-step approach simplifies the process. Start by gathering your information before you begin filling out the form.
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Ensure all information aligns with official documents.
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Describe the health conditions prompting the claim reassessment.
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Add contact details for medical professionals involved in your care.
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Check for errors or missing information to avoid submission delays.
Where to submit your AZ-113-WC form?
Once you have filled out the AZ-113-WC form, it's essential to know where to submit it. Submissions can typically be made to locations designated by the Industrial Commission of Arizona. You may also have the option to submit electronically.
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Visit their website for a list of office locations for in-person submission.
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Verify the procedures for submitting the form online.
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Be aware of any deadlines that may affect your claim.
What to expect after submission?
After you submit the AZ-113-WC form, there are several steps in the claims process you should anticipate. Familiarizing yourself with this process helps manage expectations regarding timing and necessary follow-ups.
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The Industrial Commission reviews your documentation to determine claim eligibility.
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Know the expected timeframe for a decision based on the review.
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You may need to provide additional information or attend hearings.
Common mistakes when submitting the AZ-113-WC form
Many claimants experience delays or issues due to common mistakes made during the AZ-113-WC form submission. Being aware of these can help you avoid pitfalls and submit accurately.
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Omitting essential details can lead to processing delays.
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Ensure all documents support the claim explicitly.
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Always confirm you're using the latest version of the form.
How can pdfFiller help with the AZ-113-WC form?
Using pdfFiller can streamline the process of editing and submitting the AZ-113-WC form. Their cloud-based platform allows for easy document management and collaboration, ensuring that you can work efficiently.
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Easily modify the AZ-113-WC form to ensure all information is current.
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Sign your forms securely online without needing a printer.
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Invite others to review or comment on your submissions.
How to fill out the AZ-113-WC
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1.Begin by downloading the AZ-113-WC form from the official website or your organization's portal.
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2.Open the form in pdfFiller by uploading it or importing it from your device.
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3.Carefully read the instructions provided at the top of the form for clarity.
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4.Fill out the required fields, including personal information such as name, address, and contact details in the respective sections.
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5.Provide details of the incident, including the date, time, and place of the injury, as well as a description of how the injury occurred.
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6.Complete the section regarding medical treatment received, listing healthcare providers and treatment dates.
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7.If applicable, include any previous injuries related to the current claim in the additional comments section.
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8.Review all entered information for accuracy and completeness before submitting.
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9.Save your completed form and choose the option to either print it out or submit it electronically as per your organization's directives.
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