Free SELF-INSURED HOSPITAL REPORT 2008.xls - Arizona


File Size: 9.8 kB
Pages: 1
Date: December 30, 2008
File Format: PDF
State: Arizona
Category: Workers Compensation
Author: yyang
Word Count: 233 Words, 1,531 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ica.state.az.us/forms/selfInsuredAnnualTax/Self-Insured_Hospital_Report_2008.pdf

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S E L F - I N S U R E D HOSPITAL R E P O R T F O R 2008 THE INDUSTRIAL COMMISSION OF ARIZONA
SELF INSURED NAME: PERIOD COVERED: To INSTRUCTIONS ON SEPARATE PAGE
This report is subject to verification by ICA auditors

Operating Expenses
Line 1 Line 2 Line 3 Line 4 Line 5 Line 6 Line 7 Line 8 Payroll Employee Benefits (including taxes, insurance, etc..) Surgeons' and Physicians' fees Pharmacy Miscellaneous supplies and services Depreciation Utilities Licenses and taxes

(fill in the bolded cells)

Total Operating Expenses (total of lines 1, 2, 3, 4, 5, 6, 7 & 8)
Revenue and cash flow:
Charges for services:

$

Line 9 Line 10 Line 11 Line 12 Line 13 Line 14

In-patient care Out-patient care Miscellaneous revenue Employee paid premiums Employer paid premiums

Total Revenue (total of lines 9, 10, 11, 12 & 13)

$

Line 15 Cash balance at beginning of year. Line 16 Total cash available (total of lines 14 and 15) Line 17 Investments (cash basis only) Line 18 Operating expenses (cash basis only) Line 19 Other disbursements (specify) $

Net cash balance at end of year (line 16 less lines 17, 18 and 19)
for the period stated.
Officer Signature: Officer Name: Officer Title: Date of Officer Signature: Name and Title of Person completing form if different from above: Date Form Completed: Primary Email Address: Alternative Email Address: FAX Number: Primary Phone Number: Alternative Phone Number:

$

I certify this report is a true and complete account of Operating expenses, revenue and cash flow, and net cash balances