Fill and Sign the Arizona Medical Report Form

Self-Insured:                        $                                     $       $       10. Reinsurance premiums paid (for loss limit of $             $       Signature:                   SELF-INSURED MEDICAL REPORT THE INDUSTRIAL COMMISSION OF ARIZONA Period covered: to READ INSTRUCTIONS ON REVERSE SIDE 1. Costs relating to industrial injuries: 2. Amount paid to doctors, nurses, hospitals, etc., for outside services rendered. 3. Amount paid for medications (Rx's and injections, etc.). 4. Amount paid for prosthetic devices (artificial limbs, braces, etc.). 5. Portion of hospital expenses shown on ''Hospital Report'' (line 11) for industrial injuries. 6. Remuneration of medical personnel employed by the self- insured. 7. Amount paid for first aid supplies. 8. Total medical costs for industrial-related cases during calendar year. 9. Compensation paid to claimants.). 11. Total expenditures for workmen's compensation and occupational disease claims (total of lines 8, 9, and 10. I certify this report is a true and This report subject to verification by ICA auditors. complete account of medical expenses for the period stated. Title: Date: INSTRUCTIONS FOR MEDICAL REPORT To be completed by all self-insurers for calendar year 1999. Line 2 - 4 Payments made to physicians, nurses, attendants, and hospitals, etc. and other outside services not includes in the ''Hospital Report,'' if applicable, and not assigned to a specific claim. Line 5 Portion of line 11 ''Hospital Report,'' if applicable. Line 6 Remuneration, including fringe benefits, of physicians, nurses, and attendants employed by the self-insured. Line 7 First aid equipment and supplies provided by the self-insured. Line 8 Total medical costs of industrial injuries. Line 9 Total compensation payments to claimants. Line 10 Reinsurance premiums paid for workmen's compensation. Line 11 Total costs of workmen's compensation and occupational disease.