Fill and Sign the Payroll Report for Workers Compensation Arizona Form

Self-Insured:      Page              Period Covered:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Telephone:       Signature:                   SELF-INSURED PAYROLL REPORT THE INDUSTRIAL COMMISSION OF ARIZONA of Pages ICA Plan: to: READ INSTRUCTIONS ON REVERSE SIDE (a) (b ) (c ) (d ) (e ) (f) (g) (h ) (i ) Classification Regular Pay Pay for piece Overtime Pay Executive Officer Commissions Bonuses Sick and Vacation Allowance for Hand TOTAL PAYROLL Code work, profit Pay Pay Tools, & Meals; (TOTAL OF sharing, ect Substitutes for Money COLUMNS) TOTALS This report subject to verification by ICA auditors. I certify this report is a true and complete statement of the payroll of our employees for the period stated. Title : Date : At a minimum you must segregate payroll by workers' compensation classification code and show total payroll categories must be included in the Total Payroll col