Self-Insured Employer - Annual Injury Report Form

Instructions

All Self-Insured Employers in the State of Arizona utilizing Plan C or Plan R are required to file the Self-Insured Employer - Annual Injury Report on or before February 15. The annual tax forms required for each tax plan are listed below for your convenience. 

NOTE:  AS OF APRIL 1, 2023, THE INDUSTRIAL COMMISSION WILL NO LONGER ACCEPT PAPER FORMS. ALL FORMS MUST BE FILED ELECTRONICALLY THROUGH THE WEBFORM ON THE LANDING PAGE OF THE ICA COMMUNITY. THE LINK TO THE ICA COMMUNITY IS BELOW. SELF-INSURERS ARE NOW REQUIRED TO USE A UNIQUE IDENTIFICATION NUMBER THAT WILL BE PROVIDED BY THE ICA TO ACCESS THE FORM.

Plan A Plan B Plan C and Plan R
Self-Insured Payroll Report Self-Insured Payroll Report Self-Insured Payroll Report
Self-Insured Medical Report Self-Insured Medical Report Self-Insured Medical Report
Self-Insured Injury Report   Self-Insured Injury Report  Self-Insured Injury Report 
Arizona Substitute W-9 Self-Insured Hospital Report Arizona Substitute W-9 
  Arizona Substitute W-9   

Self-Insured Employer - Annual Injury Report Form instructions are as follows:

A separate report must be prepared for the past four years with current information for both paid and reserve amounts and aggregate incurred total. 

Claim Category Claim Occurring
in CY 2022		 Claim Occurring
in CY 2021		 Claim Occurring
in CY 2020		 Claim Occurring
in CY 2019
Individual claims $10,000 and over incurred. List individually. Actual incurred amount (paid & reserved) for each claim open and closed that occurred in calendar year 2022. Actual incurred amount (paid & reserved) for each claim open and closed that occurred in calendar year 2021. Actual incurred amount (paid & reserved) for each claim open and closed that occurred in calendar year 2020. Actual incurred amount (paid & reserved) for each claim open and closed that occurred in calendar year 2019.
Individual medical and comp claims less than $10,000 incurred. Aggregate amount. Actual incurred amount (paid & reserved) for each claim open and closed that occurred in calendar year 2022. For medical and comp claims less than $10,000, update according to rule # 1 listed below. For medical and comp claims less than $10,000, update according to rule # 1 listed below. For medical and comp claims less than $10,000, update according to rule # 1 listed below.
Individual medical only claims less than $2,000 incurred. Aggregate amount. Actual incurred medical only (paid & reserved) claims open and closed that occurred in calendar year 2022. For medical claims less than $2,000, update according to rule # 1 listed below. For medical claims less than $2,000, update according to rule # 1 listed below. For medical claims less than $2,000, update according to rule # 1 listed below.
  1. Each claim must be included in one, and only one, of the three claim categories: $10,000 and over; $9,999 and under (medical & indemnity); and $1,999 and under MEDICAL ONLY. For example, if a claim has a total incurred of $1,999 and under, but has $500 indemnity listed, it must be included in the $9,999 and under category, not the $1,999 and under category. The $1,999 category is only for those claims with medical expenses with no indemnity.
  2. Claims that have occurred in any one of the past four years must be included in your report even though the claims may have been subsequently closed.
  3. Include all Vocational Rehabilitation costs paid with the Indemnity.  Place a “Y” or “N” next to each claimant name to indicate whether or not the amount entered in the Indemnity Column includes Vocational Rehabilitation.
  4. List all claimants alphabetically by last name.
  5. Under “Nature of Injury,” give a brief, but accurate, description using as much space as necessary to describe the nature of the injury.  For example, “cut thumb,” “muscle strain back,” “foreign body eye.”  Do not enter the body part affected without a description of the injury included.
  6. In addition to providing the injury reports for each year with original signature, a copy of each report, in Excel format, must be provided electronically. Separate columns for each heading must be in the following order: Payroll Class Code, Last Name, First Name, Date of Injury, Volunteer Police or Firefighter, COVID Claim, Nature of Injury, Claim Number, Medical Paid, Medical Outstanding, Indemnity Paid, Indemnity Outstanding, Expense Paid, Expense Oustanding and Subrogation/Recovery. Please list all claims big and small.
  7. If incurred amounts, paid amounts, or reserve amounts, on a single claim are less than were reported in the prior year, please provide a brief explanation of the difference. 


Please direct questions regarding the Annual Injury Report to [email protected] or call (602) 542-1836.

E-sign Electronic Submission Form

Self-Insured Employer - Annual Injury Report Form

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