Arizona > Workers Comp
Workers Compensation Liability Form - Arizona
| Workers Compensation Liability Form Form. This is a Arizona form and can be used in Workers Comp . |
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INDUSTRIAL COMMISSION OF ARIZONA WORKERS COMPENSATI ON LIABILITY FORM 1. Name of Self-Insurer: __________________________________________ 2. Security Deposit Calculation: A B C D Number of Incurred Liability Paid Amount Owing Open Claims Medical Comp . Medical Comp. Medical Comp . Cases Open in CY 2005 Cases Open as of Dec 31, 2004 Total: Total Owed from Column D: $___________ Excess insurance amount that you expect reimbursement for your excess insurance: $___________ Net remaining liability: $___________ X125%: $___________ Calculated Security Deposit: $___________ (minimum security deposit $100,000.00) 3. Name of Excess Insurance Carriers providing reimbursement: ______________________. . I attest that there is no affiliate relationship between the self-insurer and the excess insurance carrier and to the truthfulness of the above information. CFO/CEO: _______________________________ TITLE: _ ________________________ DATE: _______________________ Workers Comp Liability Form American LegalNet, Inc. www.USCourtForms.com
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