Self Insured Medical Report

This report is subject to verification by ICA auditors SELF INSURED NAME:PERIOD COVERED:ToCosts Relating to Industrial Injuries(fill in the bolded cells)Line 1**Line 2Line 3Line 4Total excess insurance reimbursements expectedI certify this report is true and complete for the period stated.Officer Signature: Officer Name: Officer Title: Date of Officer Signature: Name Title of Person completing form if different than above: Date Form : Email Address:Alternative Email Address:FAX Number:Primary Phone Number:Alternative Phone Number:N TPA:Phone Number of TPA:TPA FAX Number:If there are any questions, please contact the Tax Accountant at 602-542- or e-mail at Taxes@azica.gov NOTE : This report is a required information report on all claims paid for the calendar year, regardless of date of injury. Self-insurers will not be taxed on the amounts entered on this form. Total premiums paid for excess insurance will be for Arizona claims only, for the current calendar year, and for all claims from time of self-insurance authorization. For example, if you are paying excess insurance premiums for claims incurred in 2009, include those premiums. Total medical costs paid during calendar year 201 for all industrial-related claims. ** Include all claims from date of self-insurance authority through current calendar year-end. Medical costs include, but are not limited to: doctors, nurses, hospitals, etc.; Rx and injections; prosthetic devices; remuneration of medical personnel employed by self insured; first aid supplies. Compensation paid to claimants (indemnity) during calendar year 201 for industrial-related claims. Include all claims from date of self-insurance authority through current calendar year end. Total premiums paid durihg calendar year 201 for excess insurance. American LegalNet, Inc. www.FormsWorkFlow.com