Form Accounting ICA6623 "Notice of Self-insurer's Termination of Self-insurance Form" - Arizona

Form Accounting ICA6623 is a Industrial Commission of Arizona form also known as the "Notice Of Self-insurer's Termination Of Self-insurance Form". The latest edition of the form was released in October 15, 2017 and is available for digital filing.

Download an up-to-date Form Accounting ICA6623 in PDF-format down below or look it up on the Industrial Commission of Arizona Forms website.

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Download Form Accounting ICA6623 "Notice of Self-insurer's Termination of Self-insurance Form" - Arizona

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INDUSTRIAL COMMISSION OF ARIZONA
800 W WASHINGTON STREET
PHOENIX, ARIZONA 85007
(602) 542-4661
NOTICE OF SELF-INSURER’S TERMINATION OF SELF-INSURANCE FORM
1. Name, address and telephone number of self-insurer:
Name:
Address:
Telephone:
2. Name, address and telephone number of all Arizona subsidiaries and/or
operations (if necessary, attach supplement sheets):
Name:
Address:
Telephone:
3. Names and addresses of all partners, if self-insurer is a partnership:
Name:
Address:
4. Current and former names of self-insurer if the self-insurer has undergone a name
change since the most recent effective date of the authority to self-insure:
Current name:
Former name:
5. Effective date of termination of authority to self-insure:
ACCOUNTING ICA 6623 – REV 10.15.17
1
INDUSTRIAL COMMISSION OF ARIZONA
800 W WASHINGTON STREET
PHOENIX, ARIZONA 85007
(602) 542-4661
NOTICE OF SELF-INSURER’S TERMINATION OF SELF-INSURANCE FORM
1. Name, address and telephone number of self-insurer:
Name:
Address:
Telephone:
2. Name, address and telephone number of all Arizona subsidiaries and/or
operations (if necessary, attach supplement sheets):
Name:
Address:
Telephone:
3. Names and addresses of all partners, if self-insurer is a partnership:
Name:
Address:
4. Current and former names of self-insurer if the self-insurer has undergone a name
change since the most recent effective date of the authority to self-insure:
Current name:
Former name:
5. Effective date of termination of authority to self-insure:
ACCOUNTING ICA 6623 – REV 10.15.17
1
6. Name and address of workers’ compensation insurance carrier providing coverage
after the effective date of termination:
Name:
Address:
7. For the new coverage; effective date of workers’ compensation coverage:
8. Location of claim files occurring during the period of self-insurance:
9. Name, address, email, phone number and contact person of the third
party administrator that will continue to administer and pay the claims
that were incurred during the period of self-insurance authority:
10. Attach a copy of most current workers' compensation insurance policy.
I attest to the correctness of the above information.
______________________________
(authorized signature)
Submitter First Name:
Submitter Last Name:
Date Submitted:
Submitter Email Address:
Submitter Title:
Phone number:
ACCOUNTING ICA 6623 – REV 10.15.17
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