Free SELF-INSURED INJURY REPORT FORM 2008.xls - Arizona

SELF-INSURED INJURY REPORT FOR 2008
THE INDUSTRIAL COMMISSION OF ARIZONA
Self-Insured Name:
Page To INSTRUCTIONS ON SEPARATE PAGE
This report is subject to verification by ICA auditors

Period covered:

To

(fill in the bolded cells) (b)
Name/Date of Injury/ Nature of Injury
Indemnity Includes Vocational Rehabilitation Indicate with a (Y) or (N)

(c)

CLAIMS $5,000 AND OVER (d)
MEDICAL INDEMNITY

(fill in the bolded cells) (e) (f)
Total

List all claims alphabetically by: LAST NAME Column A Claimant Name Column B Claim #

(fill in the bolded cells) (fill in the bolded cells) Total Columns
Column C Paid Column D Outstanding Column E Paid Column F Column G Outstanding SUBROGATIONS & RECOVERIES

(C+D+E+F-G)
Total Amount Incurred

(g) Total Claims $5000 and over (h) Check total (If row g and row h do not equal, mathematical error has occurred) Total Columns (C+D+E+FColumn C Column D Column E Column F Column G G)

(j) Claims $4,999. or less: (k) Total all claims:
(l) Check total (If row k and row l do not equal, mathematical error has occurred) I certify this report is a true and complete for the period stated. Officer Signature: Officer Name: Officer Title: Date of Officer Signature: Name and Title of Person completing this form if different than above: Primary Email Address: Alternative Email Address: FAX Number: Primary Phone Number: Alternative Phone Number: NAME OF TPA: Date Form Completed: Phone Number of TPA: TPA FAX Number: