Self-Insured Employer - Annual Hospital Report Form

Instructions

All Self-Insured Employers in the State of Arizona on Tax Plan B are required to file the annual Self-Insured Employer - Annual Hospital Report Form on or before January 31. The “Hospital Report” is required of self-insurers that operate a hospital or direct medical care, pursuant to A.R.S. §23-1070.

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.

The annual tax forms required for each tax plan are listed below for your convenience.

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   

The Self-Insured Employer - Annual Hospital Report Instructions provide information on completing the Self-Insured Employer - Annual Hospital Report Form. See the Self-Insured Employer - Annual Tax Letter for a list of all the forms required for closing out the most recently completed tax year.

Fill out the form at numeric value for all categories. If there is no value for a category, please type in zero.

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

E-sign Electronic Submission Form

Self-Insured Employer - Annual Hospital Report Form

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