Arizona > Workers Comp
Self-Insured Payroll Report - Arizona
| Self-Insured Payroll Report Form. This is a Arizona form and can be used in Workers Comp . |
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SELF-INSURED PAYROLL REPORT FOR 2005 THE INDUSTRIAL COMMISSION OF ARIZONA Self-Insured: ICA Plan: Period Covered: Page to: of Pages READ INSTRUCTIONS ON REVERSE SIDE (a) Classification Code (b) Regular Pay (c) Pay for piece work, profit sharing, ect (d) Overtime Pay (e) Executive Officer Pay (f) Commissions (g) Bonuses (h) Sick and Vacation Pay (i) Allowance for Hand Tools, & Meals; Substitutes for Money TOTAL PAYROLL (TOTAL OF COLUMNS) TOTALS This report subject to verification by ICA auditors. I certify this report is a true and complete statement of the payroll of our employees for the period stated. Telephone: Signature: Title: Date: American LegalNet, Inc. www.USCourtForms.com
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