Accounting Insurance Carrier Annual Tax Instructions

All insurance companies authorized to write workers’ compensation policies in the State of Arizona are required to file Annual Workers’ Compensation Tax forms, and any associated payment, on or before March 1.

Below is the list of the annual forms that are required:

  1. Insurance Carriers Tax Year Report of Annual Workers’ Compensation Administrative Fund and Special Fund Premium Tax Form 200
  2. Certified Copy of Statutory Page 14 (Business page for Arizona of the “Annual Statement, Exhibit of Premiums and Losses)
  3. State of Arizona Substitute W-9, if a return of overpayment is due

Please ensure the following information is included as part of your annual PREMIUM TAX FORM 200:

  1. Enter “DIRECT LOSSES PAID” (From Column 5 of Statutory Page 14) in the appropriate box of Form 200.
  2. Enter “TOTAL DEDUCTIBLE POLICY LOSSES PAID” in the appropriate box of Form 200. These are total deductible policy losses processed and paid by the insurance carrier that are/were reimbursable by the employer up to the policy deductible amount (losses not included in column 5 of the Statutory Page 14).

If quarterly tax payments for the year exceeded the required annual Administrative Fund tax or Special Fund taxes for the tax year, the Industrial Commission of Arizona will issue a return of overpayment. Overpayments will not be credited against future quarterly taxes. The State of Arizona Substitute W-9 may be found at GAO State of Arizona Substitute W-9 & Vendor Authorization Form with instructions found at the bottom of the page. Return of overpayments will not be processed without a completed current State of Arizona substitute W-9.

Return the completed original Tax Form 200, a certified copy of the company’s Statutory Page 14 (Business page for Arizona) as filed with the Arizona Department of Insurance, and if applicable, a completed Arizona Substitute W-9 to:

The Industrial Commission of Arizona
Attention: Tax Accountant
800 West Washington Street, Room 301
Phoenix, Arizona 85007

IMPORTANT NOTICE: Completed forms with original signature and payments must be postmarked on or before March 1, or penalties will be assessed according to A.R.S. §23-961 (K).

Please direct questions regarding the filing of all Workers’ Compensation Taxes to [email protected] or call (602) 542-1836.