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Industrial Commission of Arizona
Protection of life, health, safety, and welfare of Arizona's workforce

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  • Agency Information
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    • Director's Office
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      • Arizona Rules
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      • All Public Meetings
      • Commission Meeting Agendas
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  • Divisions
    • Administration
      • Accounting
      • Human Resources, Special Services and MIS
      • Self-Insurance and Tax Office
    • Administrative Law Judge (ALJ) Division
    • ADOSH
      • Boiler Section
      • Elevator Section
      • Occupational Safety and Health (OSHA / ADOSH)
      • Research & Statistics (BLS)
    • Claims Division
    • Labor Department
    • Legal Division
    • Medical Resource Office (MRO)
    • Special Fund Division
  • News and Events
    • Public Notices
    • News and Events
  • Resources For
    • Resources for Employees
    • Resources for Employers
    • Resources for Insurers
    • Resources for Medical Providers
    • Resources for ICA Community
  • How Do I
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    • Self Service Center
    • ICA Community
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  • Accounting Self-Insured Employer Annual Hospital Report Form

Accounting Self-Insured Employer Annual Hospital Report Form

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.

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.

Required Forms

Form Name Last Updated
Self-Insured Employer - Annual Hospital Report Form 01/20/23
Self-Insured Employer - Annual Hospital Report Form 01/20/23

Official Website of the State of Arizona

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Contact Us:

Phoenix Office
800 W. Washington Street
Phoenix AZ 85007
602-542-4661

 

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Contact Us:

Tucson Office
2675 E. Broadway Blvd
Tucson AZ 85716
520-628-5188

 

 

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