Free INDUSTRIAL COMMISSION OF ARIZONA - Arizona

INDUSTRIAL COMMISSION OF ARIZONA WORKERS' COMPENSATION LIABILITY FORM
1. 2. NAME OF SELF-INSURER: ________________________________________________________ SECURITY DEPOSIT CALCULATION (Number of Claims, Incurred Liability and Paid amounts must be calculated from the Effective Date of Self-Insurance Authority to the present date):

A
Total Amount of Open Claims

B
Incurred Medical

C
Paid Medical

D
Total Medical Owed (B ­ C = D)

E
Incurred Comp.

F
Paid Comp.

G
Total Comp. Owed (E ­ F = G)

H
TOTAL ALL CLAIMS (D + G = H)

Total Owed from Column H: Excess insurance reimbursement amount expected: Net remaining liability: Multiply by 125%: Calculated Security Deposit: (minimum security deposit $100,000.00)

$_______________ $_______________ $_______________ $_______________ $_______________

3. Name of Excess Insurance Carriers providing reimbursement: (provide detailed report with carrier name, SIR amount, claimant names, DOI and claim number, reimbursement amount requested)
(List the Policy Year(s) of Reimbursement taken) _________________________________________________

I, ____________________________ attest that there is no affiliate relationship between the selfinsurer and the excess insurance carrier and to the truthfulness of the above information.
4. .
EMPLOYEE COUNT

Total Employee Count from prior anniversary date to current (include all full & part time employees that worked regardless of whether or not they are still employed.) Explain decrease on separate cover. _____________________________________ Self-Insurers Authorized Representative Signature: ____________________________________________

Printed Name/Title: ____________________________________________

DATE: _____________________
Workers' Comp Liability Form

* Must be signed by Designated Officer