Fill and Sign the Injury Workers Compensation Form

Self-insured:      Page                    Period covered:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Signature:                         SELF-INSURED INJURY REPORT THE INDUSTRIAL COMMISSION OF ARIZONA of Pages to READ INSTRUCTIONS ON REVERSE SIDE (a ) Claims over $5,000(b) (C ) (d ) (i) Name/Date of Injury/ Nature of Injury Medical Compensation Total (e) (f) (g ) (h ) Paid Outstanding Paid Outstanding ( j) Claims $5,000 or less (k ) Total all claims This report subject to verification by ICA auditors I certify this report is a true and complete statement of losses for the period stated. Title: Date: Telephone :                              INSTRUCTIONS FOR SELF-INSURED INJURY REPORT 1. A separate report must be prepared for CY 1999, 1998, 1997, and 1996. The 1998, 1997, and 1996 reports update those previous reports. Claims Occurring Claims Occurring Claims Occur Claims Occurring M CY 1999 M CY 1998 in CY 1997 Individual claims Actual amount Actual amount Actual amount over $5,000. List paid plus reserves paid in 1999 and paid in 1999, 1998, 1998, individually. for each claim 1998 on 1998 claims and 1997 on 1997 which occurred in plus reserves on claims plus reserves 1999. open claims. on open claims. Individual claims Actual amount For claims under For claims under $5,000 and under. paid plus reserves $5,000, update $5,000, update Report aggregate on claims which according to rules according to rules according to rules amount. occurred in 1999. shown above. shown above. Tota l Total for 1999. Claims that have occurred in one of these years must be included though the claims may have been closed. For example, ''cut thumb ... .. muscle strain back ... .. foreign body eye. 2. Under ''Name/Date of Injury/Nature of Injury,'' column (b), be brief but accurate using as much space as necessary to describe in detail 11 Do not simply describe the part of body injured.