Skip to main content

Industrial Commission of Arizona

0
  • Home
  • Agency Information
    • About Us
    • Commissioners
    • Director's Office
    • Legislation
      • Arizona Statutes
      • Arizona Rules
    • Meetings
      • All Public Meetings
      • Commission Meeting Agendas
      • Meeting Minutes
  • 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
  • Online Services
    • Forms
    • Self Service Center
    • ICA Community
  • Payment Portal
  • OMBUDSMAN
Industrial Commission of Arizona Logo
Industrial Commission of Arizona
Protection of life, health, safety, and welfare of Arizona's workforce

Follow Industrial Commission of Arizona on:

Main menu

  • Home
  • Agency Information
    • About Us
    • Commissioners
    • Director's Office
    • Legislation
      • Arizona Statutes
      • Arizona Rules
    • Meetings
      • All Public Meetings
      • Commission Meeting Agendas
      • Meeting Minutes
  • 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
  • Online Services
    • Forms
    • Self Service Center
    • ICA Community
  • Payment Portal
  • OMBUDSMAN
  • Home
  • Self-Insurance Annual Tax Forms

Self-Insurance Annual Tax Forms

Administrative Support Division
Self-Insurance Section
Phone: (602) 542-1839

 

TO ACCESS FORMS OR INSTRUCTIONS, CLICK ON A LINK BELOW.

 

  • 2015 Self-Insured Annual Tax Forms
     
    • 2015 Annual Letter (PDF)
    • 2015 Hospital Report Form (Excel)
    • 2015 Hospital Report Instructions (PDF)
    • 2015 Injury Report Form (Excel)
    • 2015 Injury Report Instructions (PDF)
    • 2015 Medical Report Form (Excel) (Instructions are included on form for 2015.)
    • 2015 Payroll Report Form (Excel)
    • 2015 Payroll Report Instructions (PDF)

 

  • 2014 Self-Insured Annual Tax Forms
     
    • 2014 Annual Letter (PDF)
    • 2014 Hospital Report Form (Excel)
    • 2014 Hospital Report Instructions (PDF)
    • 2014 Injury Report Form (Excel)
    • 2014 Injury Report Instructions (PDF)
    • 2014 Medical Report Form (Excel) (Instructions are included on form for 2014.)
    • 2014 Payroll Report Form (Excel)
    • 2014 Payroll Report Instructions (PDF)

 

  • 2013 Self-Insured Annual Tax Forms
     
    • 2013 Annual Letter (PDF)
    • 2013 Hospital Report Form (Excel)
    • 2013 Hospital Report Instructions (PDF)
    • 2013 Injury Report Form (Excel)
    • 2013 Injury Report Instructions (PDF)
    • 2013 Medical Report Form (Excel) (Instructions are included on form for 2013.)
    • 2013 Payroll Report Form (Excel)
    • 2013 Payroll Report Instructions (PDF)

 

  • 2012 Self-Insured Annual Tax Forms
     
    • 2012 Annual Letter (PDF)
    • 2012 Hospital Report Form (Excel)
    • 2012 Hospital Report Instructions (PDF)
    • 2012 Injury Report Form (Excel)
    • 2012 Injury Report Instructions (PDF)
    • 2012 Medical Report Form (Excel) (Instructions are included on form for 2012.)
    • 2012 Payroll Report Form (Excel)
    • 2012 Payroll Report Instructions (PDF)

 

  • 2011 Self-Insured Annual Tax Forms
     
    • 2011 Annual Letter (PDF)
    • 2011 Hospital Report Form (PDF)
    • 2011 Hospital Report Instructions (PDF)
    • 2011 Injury Report Form (PDF)
    • 2011 Injury Report Instructions (PDF)
    • 2011 Medical Report Form (PDF) (Instructions are included on form for 2011.)
    • 2011 Payroll Report Form (PDF)
    • 2011 Payroll Report Instructions (PDF)

 

  • 2010 Self-Insured Annual Tax Forms
     
    • 2010 Annual Letter (PDF)
    • 2010 Hospital Report Form (PDF)
    • 2010 Hospital Report Instructions (PDF)
    • 2010 Injury Report Form (PDF)
    • 2010 Injury Report Instructions (PDF)
    • 2010 Medical Report Form (PDF)
    • 2010 Medical Report Instructions (PDF)
    • 2010 Payroll Report Form (PDF)
    • 2010 Payroll Report Instructions (PDF)

 

  • 2009 Self-Insured Annual Tax Forms
     
    • 2009 Annual Letter (PDF)
    • 2009 Hospital Report Form (PDF)
    • 2009 Hospital Report Instructions (PDF)
    • 2009 Injury Report Form (PDF)
    • 2009 Injury Report Instructions (PDF)
    • 2009 Medical Report Form (PDF)
    • 2009 Medical Report Instructions (PDF)
    • 2009 Payroll Report Form (PDF)
    • 2009 Payroll Report Instructions (PDF)

 

ICA Community is NOW LIVE

Join the ICA Community Now!

Resources for the ICA Community

Wage Information

  • 2023 AMW Statutory Max - $5,393.37 
  • 2023 Minimum Wage - $13.85 per hour
  • 2022 AMW Statutory Max - $5,161.12 
  • 2022 Minimum Wage - $12.80 per hour 

Job Opportunities at the ICA

Job Opportunities at the ICA

Public Notices

  • 05/26/23 Notice of Public Hearing Regarding 2023-2024 Physicians’ and Pharmaceutical Fee Schedule on June 29, 2023
  • 04/24/23 Notice of Public Hearing Regarding One-Half Percent Assessment Under A.R.S § 23-1065(F) on May 25, 2023
Public Notice Archive

Recent News & Events

  • 05/19/23 ICA Claims Seminar - Registration Now Open
  • 02/01/23 New Medical Resource Office Trainings Available
  • 12/06/22 Rule 20-5-1534 Self-Insurance Q&A
  • 09/15/22 2023 Minimum Wage Increase
  • 06/09/22 Cancer Claim Reporting and MFCR Training
Recent News Archive

Official Website of the State of Arizona

phoenix map

Contact Us:

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

 

tucson map

Contact Us:

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

 

 

Arizona State Seal

Footer Nav

  • Statewide Policies
  • Site Map
  • The Ombudsman-Citizens Aide helps citizens to resolve ongoing issues with State Agencies