Can the report be signed electronically?

Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96, 2000) and UETA where adopted, provided signer intent, consent and retention requirements are met.

What if the employee changes details later?

Create an addendum noting the date of the change, the corrected facts, and who approved the amendment; retain the original report and the amendment for audit purposes.

Are medical records protected when attached?

Medical attachments containing PHI must be handled under HIPAA rules; use a BAA with vendors and limit access to authorized parties only.

Is notarization required for the report?

Not typically required for routine injury reports, but some jurisdictional or insurer processes may request notarization for sworn statements or affidavits.

How do I correct an error on a submitted report?

Do not overwrite the original; submit a supplemental report or correction notice that references the original and explains the change.

Who should I contact after submission?

Retain the TPA or self-insurer claims contact and your internal safety officer information so claim handlers can request follow-up details quickly.

Electronic Signature
Templates
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Self-Insured Injury Report

Self-Insured Injury Report

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

SELF-INSURED INJURY REPORT

THE INDUSTRIAL COMMISSION OF ARIZONA

Self-insured: Page of

Pages

Period covered: to READ INSTRUCTIONS ON REVERSE SIDE

(a) Claims over $5,000

(b) Name/Date of Injury/Nature of Injury

(c) Medical

(e) Paid

(f) Outstanding

(d) Compensation

(g) Paid

(h) Outstanding

(i) Total

(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.

Signature:

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 in CY 1999: Individual claims over $5,000 list individually; actual amount paid plus reserves for each claim which occurred in 1999. Individual claims $5,000 and under report aggregate amount; actual amount paid plus reserves on claims which occurred in 1999.

Claims occurring in CY 1998: Actual amount paid in 1999 and 1998 on 1998 claims plus reserves on open claims. For claims under $5,000, update according to rules shown above.

Claims occurring in CY 1997: Actual amount paid in 1999, 1998, and 1997 on 1997 claims plus reserves on open claims. For claims under $5,000, update according to rules shown above.

Total: Total for 1999. Claims that have occurred in one of these years must be included though the claims may have been closed.

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. Do not simply describe the part of body injured.

What a Self-Insured Injury Report Is and when it’s used

A Self-Insured Injury Report documents a workplace injury or occupational illness when an employer pays claims from its own funds or through a self-insured trust. The report records employee details, incident date/time, location, injury description, witnesses, medical treatment and employer contact data. Employers, third-party administrators (TPAs), and claims examiners use the document to decide benefits, coordinate care, and meet state workers’ compensation or insurance-reporting obligations. Accurate reports create the record of notice for claims processing, help establish compensability, and support audit and legal review if disputes arise.

Why a precise Self-Insured Injury Report matters

A clear, complete report reduces processing delays, preserves evidence, and shapes benefits decisions while establishing the employer’s notice. Proper documentation supports claim acceptance or denial, protects legal positions, and helps identify workplace safety trends for corrective action.

Primary users and recipients of this report

The report is used by multiple internal and external roles during claim intake and resolution.

Employer safety or HR teams responsible for incident logging, initial fact gathering and internal notifications.
Third-party administrators and self-insurance funds that evaluate compensability, assign reserves and manage payments.
Medical providers and treating clinicians who use incident details to link care to the workplace injury.

Step-by-step: completing and submitting the report

Follow a consistent sequence to capture accurate facts and avoid omissions that delay claims handling.

01

1. Record incident: Document the facts while fresh, including witnesses and photos if available.
02

2. Notify employer: Inform HR or the safety officer immediately, per internal policy.
03

3. Complete report: Fill all required fields and attach medical notes or photos.
04

4. Submit to TPA: Send report to the self-insurer or TPA and keep a routed copy.

How electronic submission typically flows

An eSubmission workflow shortens response time and creates an audit trail; understand each automated step.

Upload: Sender uploads the completed PDF or form to the claims portal.
Field mapping: System extracts key fields for the claims database and routing rules.
Review: Claims examiner reviews attachments, medical entries, and witness statements.
Acknowledge: System issues receipt and logs timestamps for compliance.

Recommended digital workflow settings for consistent intake

Configure the form and routing so required fields are enforced and claim handlers are notified automatically.

Field	Configuration
Signers	Employee \| Employer representative
Authentication	Email link \| SMS one-time passcode
Conditional Fields	Show treatment fields if 'Medical care' selected
Attachments	Accept PDF \| JPG \| DOCX

Technical and integration considerations

Ensure the eSubmission platform supports required formats, authentication, and downstream integrations.

File Formats: PDF, DOCX, JPG supported
Integrations: CRM and TPA systems via API
Authentication: Email, SMS OTP, optional KBA

What a professional Self-Insured Injury Report contains

Well-structured reports separate facts, medical data and investigation findings so each reviewer can act quickly.

Incident details

Precise date/time, location and immediate conditions describing the event, which anchor causal and compensability analysis.

Parties and roles

Employee name, job title, shift, supervisor and witness names with contact information for follow-up and statements.

Injury description

Body part(s) affected, observable signs, onset of symptoms, and mechanism of injury recorded plainly and without legal conclusions.

Witness statements

Contemporaneous witness descriptions and contact details; note whether written or oral and attach signed statements where possible.

Medical documentation

Provider notes, diagnostic results, and transport or referral records that substantiate treatment and work restrictions.

Investigation summary

Employer findings, corrective actions proposed, and whether the area was secured for inspection to reduce recurrence.

Security and compliance points to include

HIPAA compliance: BAA required for PHI

Encryption: TLS 1.2/1.3 and AES-256

Audit trail: Timestamps, IP, and actions

Access controls: Role-based permissions

Retention controls: Tamper-evident storage

Regulatory certs: SOC 2 Type II, ISO 27001

Common mistakes that cause delays or disputes

Omitting the precise time or place of the incident, which complicates verification and medical correlation.
Using vague descriptions like 'hurt myself' rather than describing mechanism and body parts, reducing evidentiary value.
Failing to attach medical records or witness contact information, requiring follow-up and extending adjudication time.
Not preserving photographs, equipment logs or area conditions, which weakens investigation and subrogation opportunities.

Potential legal and operational risks

Delayed benefits: Increased indemnity and medical costs

Regulatory fines: Late state reporting penalties

Evidence loss: Weakened legal position

Reserve exposure: Higher insurer reserves

Litigation risk: Greater chance of suit

Reputation harm: Stakeholder trust erodes

Timing expectations and typical deadlines

Timely reporting reduces denials and supports early medical management; specifics vary by company policy and state law.

Immediate report to employer:

Report as soon as practicable, ideally the same business day.

Employer to TPA:

Submit completed report within employer policy window, commonly 24–72 hours.

Medical care:

Provide or authorize treatment promptly and document providers and referrals.

Formal claim filing:

File required insurer or state forms per jurisdiction-specific deadlines.

Document retention:

Keep originals and copies per retention schedule and regulatory requirements.

Key processing milestones from incident to resolution

Track milestones as discrete stages to maintain compliance and keep stakeholders informed throughout the claim lifecycle.

01

Incident Occurs

Immediate facts recorded and urgent medical needs addressed.

02

First Report

Employee or supervisor completes initial injury report and notifies employer.

03

Claims Intake

Report sent to self-insurer or TPA for assignment and triage.

04

Investigation & Resolution

Medical review, reserve setting and final disposition occur.

Illustrative use cases showing typical outcomes

Two brief scenarios show how a complete report improves decision-making, triage and payment accuracy.

On-site minor injury

A warehouse worker slips while securing a load and reports shoulder pain the same day.

The supervisor documents witness names, photos, and time of injury.
Timely reporting allowed the TPA to authorize conservative care, avoid unnecessary ER visits and close the claim as medical-only with minimal indemnity exposure.

Serious off-site incident

A field technician sustains a fracture during client service and is transported to hospital immediately.

Employer records travel details and treating facility contact.
Prompt submission with provider notes enabled quick authorization for specialty care and a coordinated return-to-work plan that reduced time away from full duty.

Who signs and certifies the report

Safety Manager — Employer Representative

Typically completes and certifies the employer-side section, confirms investigation steps, and attests to the accuracy of the employer-provided facts for claim intake and audit trails.

Claims Adjuster — Insurer/TPA

Reviews and signs the adjudication section to confirm receipt, reserve setting, and decision milestones; documents any follow-up information requests.

Common eSignature vendor pricing and capability comparison

Basic price and core capabilities differ across providers; signNow is listed first to show a competitively priced option with core compliance features.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about completing and submitting the report

Answers to common questions on signatures, corrections, data privacy and next steps after filing.

Need help? Contact support

Can the report be signed electronically?
Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96, 2000) and UETA where adopted, provided signer intent, consent and retention requirements are met.
What if the employee changes details later?
Create an addendum noting the date of the change, the corrected facts, and who approved the amendment; retain the original report and the amendment for audit purposes.
Are medical records protected when attached?
Medical attachments containing PHI must be handled under HIPAA rules; use a BAA with vendors and limit access to authorized parties only.
Is notarization required for the report?
Not typically required for routine injury reports, but some jurisdictional or insurer processes may request notarization for sworn statements or affidavits.
How do I correct an error on a submitted report?
Do not overwrite the original; submit a supplemental report or correction notice that references the original and explains the change.
Who should I contact after submission?
Retain the TPA or self-insurer claims contact and your internal safety officer information so claim handlers can request follow-up details quickly.

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