Free SELF-INSURED PAYROLL REPORT 2008.xls - Arizona

SELF-INSURED PAYROLL REPORT FOR 2008
THE INDUSTRIAL COMMISSION OF ARIZONA
Self-Insured Name: ICA Plan: Period Covered: (a)
Classification Code
This report is subject to verification by ICA auditors

Page

of
INSTRUCTIONS ON SEPARATE PAGE

Pages

From (b)
Regular Pay

To (c)
Pay for piece work, profit sharing, etc.

(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

(fill in the bolded cells) (j)
TOTAL PAYROLL

TOTAL of COLUMNS (b + c + e + f + g + h + i) $ $ $ $ $ $ $ $ $ $ $ $ $ $

Column Totals

$

$

$

$

$

$

$

$

Total Payroll Row Total (If Column Totals does not equal Total Payroll Row total, a mathematical error has occurred) Total employee count for calander year (Total number of employees that worked in the current calander year) 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 form if different than above: Primary Email Address: Alternative Email Address: FAX Number: Primary Phone Number: Alternative Phone Number:

Date Form Completed: