Free SELF-INSURED MEDICAL REPORT 2008.xls - Arizona

S E L F - I N S U R E D MEDICAL R E P O R T F O R 2 0 0 8 THE INDUSTRIAL COMMISSION OF ARIZONA
SELF INSURED NAME:
This report is subject to verification by ICA auditors

PERIOD COVERED:

To

INSTRUCTIONS ON SEPARATE PAGE

Costs Relating to Industrial Injuries
(fill in the bolded cells) Line 1 Amount paid to doctors, nurses, hospitals, etc., for outside services rendered. Line 2 Amount paid for medications (Rx's and injections, etc.). Line 3 Amount paid for prosthetic devices (articial limbs, braces, etc.). Line 4 Portion of Hospital expenses shown in "Hospital Report" (line 8) for industrial injuries. (incurred not directly paid) Line 5 Remuneration of medical personnel employed by the self-insured. Line 6 Amount paid for first aid supplies.
Total medical costs for industrial-related cases during calender year. (Total Lines 1 - 6)

$

Line 7 Compensation paid to claimants. Line 8 Reinsurance premiums paid.

Total expenditures for workers compensation and occupational disease claims. (Total Lines 7-8)

$

I certify this report is a 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:

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: