Arizona > Workers Comp
Self-Insured Injury Report - Arizona
| Self-Insured Injury Report Form. This is a Arizona form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
SELF-INSURED INJURY REPORT FOR 2005 THE INDUSTRIAL COMMISSION OF ARIZONA Self-insured: Page of Pages Period covered: to READ INSTRUCTIONS ON REVERSE SIDE (a) Claims over $5,000 (b) Name/Date of Injury/ Nature of Injury Indemnity Includes Vocational Rehabilitation Indicate with a (Y) or (N) (e) Paid (c) MEDICAL (d) INDEMNITY (i) Total (f) Outstanding (g) Paid (h) Outstanding (j) Claims $5,000 or less (k) Total all claims This report subject to verification by ICA auditors Signature: I certify this report is a true and complete statement of losses for the period stated. Title: Telephone: Date: American LegalNet, Inc. www.USCourtForms.com
|
|||||||
