Accounting Self-Insured Employer Annual Medical Report Form

The Arizona Workers Compensation Tax annual forms are due on or before January 31 for all Arizona authorized self-insured employers. The annual tax forms required for each tax plan are listed below for your convenience.

All self-insured employers must complete the Annual Medical Report. Report Requirements are as follows:

  • Line 1 - Total medical costs paid during calendar year for all industrial-related claims. Include all claims from date of self-insurance authority through current calendar year-end. Medical costs include, but are not limited to: doctors, nurses, hospitals, prescriptions, injections, prosthetic devices, remuneration of medical personnel employed by self-insured, first aid supplies, etc.                                                           
  • Line 2 - Compensation paid to claimants (indemnity) during the calendar year for industrial-related claims. Include all claims from date of self-insurance authority through current calendar year end.                   
  • Line 3 - Total premiums paid during the calendar year for excess insurance.
  • Line 4 - Total excess insurance reimbursements expected. 

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

Arizona Revised Statutes

Any insurer failing to pay taxes on time shall be charged a penalty of the greater of twenty-five dollars, or five percent of the tax due plus interest at the rate of one percent per month from the date the tax was due. A.R.S. § 23-961 (K)

Any insurer, which has paid or is required to pay a tax of two thousand dollars ($2,000) or more for the preceding calendar year, shall file a quarterly report accompanied by a payment in an amount equal to the tax due.  A.R.S. § 23-961 (I)

Administrative Fund Tax

A.R.S. § 23-961 (G) Every self-insured employer, including workers' compensation pools, on or before March 31 of each year shall pay a tax of not more than three per cent of the premiums that would have been paid by the employer if the employer had been fully insured by an insurance carrier authorized to transact workers' compensation insurance in this state during the preceding calendar year. The commission shall adopt rules that shall specify the premium plans and methods to be used for the calculation of rates and premiums and that shall be the basis for the taxes assessed to self-insured employers. The tax shall be not less than two hundred fifty dollars per annum and shall be computed and collected by the commission and paid to the state treasurer for the credit of the administrative fund at a rate not exceeding three per cent to be fixed annually by the industrial commission. The rate shall be no more than is necessary to cover the actual expenses of the industrial commission in carrying out its powers and duties under this title. Any quarterly payments of tax pursuant to subsection I of this section shall be deducted from the tax payable pursuant to this subsection.

Special Fund Tax

A.R.S. § 23-1065 (A) The industrial commission may direct the payment into the state treasury of not to exceed one per cent of all premiums received by private insurance carriers during the immediately preceding calendar year. The same percentage shall be assessed against self-insurers based on the total cost to the self-insured employer as provided in section 23-961, subsection G. Such assessments shall be computed on the same premium basis as provided for in section 23-961, subsections G, H, I, J and K and shall be no more than is necessary to keep the special fund actuarially sound. Such payments shall be placed in a special fund within the administrative fund to provide, at the discretion of the commission, such additional awards as may be necessary to enable injured employees to accept the benefits of any law of this state or of the United States, or both jointly, for promotion of vocational rehabilitation of persons with disabilities in industry.

Apportionment Tax

A.R.S. § 23-1065 (F) ... If the total annual reserved liabilities of the special fund obligated under subsections B and C of this section exceed six million dollars, as determined by the annual actuarial study performed pursuant to subsection I of this section, the commission, after notice and a hearing, may levy an additional assessment under subsection A of this section of up to one-half per cent to meet such liabilities…