Accounting Self-Insured Employer Annual Tax Letter
The Arizona Annual Workers Compensation Tax annual forms are due on or before February 15 for all Arizona authorized self-insured employers. 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 |
Plan C and Plan R: 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 via email or CD. Separate columns for each heading must be in the order: Last Name, First Name, Date of Injury, Nature of Injury, Claim Number, Medical Paid, Medical Outstanding, Indemnity Paid, Indemnity Outstanding, and Subrogation/Recovery.
Plan C and Plan R: If incurred amounts, paid amounts, or reserve amounts, on a single claim, are less than were reported in the prior year, please provide a brief explanation of the difference.
All Plans: If the reported payroll, by classification code, is lower than the payroll reported for the prior year, please provide a brief explanation of the difference.
The State of Arizona Substitute W-9 may be found here 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.
Please return all completed forms with original signature to:
The Industrial Commission of Arizona
Attention: Tax Accountant
800 West Washington Street, Room 301
Phoenix, AZ 85007
E-mailed annual tax forms are accepted for preliminary tax calculation only. Original annual tax forms, with signatures, must be received or final tax calculation will not be processed.
Please direct questions regarding the filing of all Workers Compensation Taxes to [email protected] or call (602) 542-1836.
