Arizona > Workers Comp
Notice Of Self-Insurers Termination Of Self-Insurance Form - Arizona
| Notice Of Self-Insurers Termination Of Self-Insurance Form Form. This is a Arizona form and can be used in Workers Comp . |
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INDUSTRIAL COMMISSION OF ARIZONA NOTICE OF SELF-INSURERS TERMINAT ION OF SELF-INSURANCE FORM 1. Name, address and telephone number of self-insurer: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2. Name, address and telephone numbe all Arizona subsidiaries and/or r of operations (if necessary, attach supplement sheets): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 3. Names and addresses of all partners, if self-insurer is a partnership: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 4. Current and former names of self-insurer if the self-insurer has undergone a name change since the most recent effective date of the authority to self-insure: Current name: _______________________________________________ Former name: _______________________________________________ 5. Effective date of termination of authority to self-insure: ____________________ Notice of Self-Insurers Term of S.I. Form 1 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 6. Name and address of workers compensation insurance carrier providing coverage after the effective date of termination: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 7. For the new coverage; effective date of workers compensation coverage: __________________________________________________________________ 8. Location of claim files occurring during the period of self-insurance: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ I attest to the correctness of the above information. ______________________________ (authorized signature) Title: _________________________ Phone number: _________________ Notice of Self-Insurers Term of S.I. Form 2 American LegalNet, Inc. www.USCourtForms.com
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