Accounting Self-Insured Employer Annual Injury Report Form
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.
| 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 |
| Arizona Substitute W-9 | Self-Insured Hospital Report | Self-Insured Injury Report for the Past Four Years |
| 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 2019 | Claim Occurring in CY 2018 | Claim Occurring in CY 2017 | Claim Occurring in CY 2016 |
| 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 2019. | Actual incurred amount (paid & reserved) for each claim open and closed that occurred in calendar year 2018 | Actual incurred amount (paid & reserved) for each claim open and closed that occurred in calendar year 2017 | Actual incurred amount (paid & reserved) for each claim open and closed that occurred in calendar year 2016 |
| 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 2019. | 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 2019. | 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. |
- 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.
- 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.
- 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.
- List all claimants alphabetically by last name.
- 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.
- 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: Last Name, First Name, Date of Injury, Nature of Injury, Claim Number, Medical Paid, Medical Outstanding, Indemnity Paid, Indemnity Outstanding and Subrogation/Recovery.
- Substitute forms may be used in place of the injury report form, as long as they include the exact information in the exact same format as the injury report form. In the case that a substitute form is used, the injury report form must be used as a summary sheet and it must be signed and dated by an authorized signer.
Please direct questions regarding the Annual Injury Report to [email protected] or call (602) 542-1836.
