Fill and Sign the Arizona Workers Compensation Form

Self Insured:      Period covered:             $                                                 $                                     $                                     $                   SELF-INSURED HOSPITAL REPORT THE INDUSTRIAL COMMISSION OF ARIZONAto READ INSTRUCTIONS ON REVERSE SIDE 1. Operating expenses: 2. Payroll. 3. Employee benefits (including payroll taxes, insurance, etc.) 4. Surgeons' and physicians' fees. 5. Pharmacy. 6. Miscellaneous supplies and services. 7. Depreciation. 8. Utilities. 9. Licenses and taxes. 11. Total operating expenses 12. Revenue and cash flow: 13. Charges for services: 14. In-patient care. 15. Out-patient care. 16. Miscellaneous revenue. 17. Employee paid premiums. 18. Employer paid premiums. 19. Total revenue 20. Cash balance at beginning of year. 21. Total cash available (total of lines 19 and 20). 22. Investments (cash basis only). 23. Operating expenses (cash basis only). 24. Other disbursements (specify). 25. Net cash balance at end of year (line 21 less lines 22, 23 and 24). This report subject to verification byICA auditors I certify this report is a true and complete account ofoperating expenses, revenue and cash flow, and net cash balances for the period stated. Signature: Title: Date: INSTRUCTIONS FOR HOSPITAL REPORT The ''Hospital Report'' is required of self-insurers that operate a hospital, pursuant to A.R.S. 23-1070. Line s 1 - 11 Show the total cost of operations of the hospital for the calendar year. Line s 12 - 19 Show all revenue received by the hospital during the calendar year. Line s 20 - 25 Show the cash flow for the calendar year.