Free Self Insured Quarterly - Arizona

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INDUSTRIAL COMMISSION OF ARIZONA SELF-INSURER'S QUARTERLY ADMINISTRATIVE AND SPECIAL FUND TAX PAYMENT FORM 103 FOR 2008
FROM: Self-Insured Name March 31, 2008 June 30, 2008 September 30, 2008 December 31, 2008 City State Zip code DUE DUE DUE DUE April 30, 2008 July 31, 2008 October 31, 2008 January 31, 2009

Street Address

COMPUTATION OF QUARTERLY TAXES
Insurers who were required to pay an Administrative Fund tax of at least $2000 for the preceding calendar year
must file this report and pay the taxes calculated for the current calendar year. A.R.S. § 23-961 (L).

A. Method I
1 2007 Net Taxable Premium (Reference Form 100, Line A or Form 101, Line 1) 2 Administrative Tax - Multiply Line 1 by 3.00% or 0.03 3 Multiply Line 2 by 25% or 0.25 4 Special Fund tax - Multiply line 1 by 1.50% or .015 5 Multiply Line 4 by 25.0% or 0.25 6 Add lines A3 & A5 together and pay this amount Line A1 $ Line A2 $ Line A3 $ Line A4 $ Line A5 $ Line A6 $

ADMINISTRATIVE FUND SPECIAL FUND A.R.S. § 23-961 (L)

B. Method II
This method will be based on actual payroll, by Workers' Compensation Code, for the applicable quarter. If this method is selected, please contact us and we will mail the necessary payroll and injury report forms.
Penalty and interest will be assessed for failing to pay the tax on time: The greater of twenty-five dollars or five percent of the tax due plus interest at the rate of one percent per month from the date the tax was due, which is 30 days after close of the quarter. A.R.S. § 23-961 (N) Please return the COMPLETED FORM with your check payable to Industrial Commission of Arizona for the total payment due and mail to:

Industrial Commission of Arizona Attention: Tax Accountant 800 West Washington Street, Suite 301 Phoenix, Arizona 85007

If there are any questions, please contact the Tax Accountant at 602-542-1836 or e-mail at [email protected] I certify that the foregoing is correct to the best of my knowledge and belief: (please complete all of the information) 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: Alternative Phone Number: Date Form Completed: