Form Accounting ICA6611 "Self-insured Employer - Annual Injury Report Form" - Arizona

What Is Form Accounting ICA6611?

This is a legal form that was released by the Industrial Commission of Arizona - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 5, 2019;
  • The latest edition provided by the Industrial Commission of Arizona;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form Accounting ICA6611 by clicking the link below or browse more documents and templates provided by the Industrial Commission of Arizona.

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Download Form Accounting ICA6611 "Self-insured Employer - Annual Injury Report Form" - Arizona

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This report is subject to verification by ICA auditors
INDUSTRIAL COMMISSION OF ARIZONA
800 W WASHINGTON STREET
PHOENIX, ARIZONA 85007
(602) 542-4661
S E L F - I N S U R E D I N J U R Y R E P O R T F O R 2 0 1 9
Self-Insured Name:
Period covered:
To
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 only, no indemnity.
(A) CLAIMS $10,000 AND OVER
MEDICAL
INDEMNITY
Enter As Negative
Total Columns
List alphabetically by Last Name
Column B
Column C
Column D
Column E
Column F
Column G
(C+D+E+F+G)
Rehab
SUBROGATIONS &
Last Name
First Name
DOI
Nature of Injury
Claim #
Paid
Outstanding
Paid
Outstanding
Total Amount Incurred
Y/N
RECOVERIES
This form will not be considered complete without the required Excel file provided electronically.
The Excel file may be emailed to taxes@azica.gov. However, the signature page must be
electronically signed and submitted.
Download Self Insured Annual Injury Report Excel File
(G) Total Claims $10,000 and over
0.00
Column C
Column D
Column E
Column F
Column G
Total Columns (C+D+E+F+G)
(I) Claims $1,999 or less Medical only
(If included here, do not include in Line J)
(J) Claims $9,999 or less Medical and/or Indemnity:
(K) Total all claims:
0.00
I certify this report is a true and complete for the period stated.
Submitter Email Address:
Officer Signature:
Alternative Email Address:
Officer Name:
Primary Phone Number:
Officer Title:
Alternative Phone Number:
Date of Officer Signature:
Fax Number:
Name and Title of Person completing this form if different than above:
TPA Name:
Date Form Submitted:
TPA Phone Number:
If there are any questions, please contact the Tax Accountant at 602-542-4654 or e-mail at Taxes@azica.gov
ACCOUNTING ICA 6611 – REV 12.5.19
This report is subject to verification by ICA auditors
INDUSTRIAL COMMISSION OF ARIZONA
800 W WASHINGTON STREET
PHOENIX, ARIZONA 85007
(602) 542-4661
S E L F - I N S U R E D I N J U R Y R E P O R T F O R 2 0 1 9
Self-Insured Name:
Period covered:
To
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 only, no indemnity.
(A) CLAIMS $10,000 AND OVER
MEDICAL
INDEMNITY
Enter As Negative
Total Columns
List alphabetically by Last Name
Column B
Column C
Column D
Column E
Column F
Column G
(C+D+E+F+G)
Rehab
SUBROGATIONS &
Last Name
First Name
DOI
Nature of Injury
Claim #
Paid
Outstanding
Paid
Outstanding
Total Amount Incurred
Y/N
RECOVERIES
This form will not be considered complete without the required Excel file provided electronically.
The Excel file may be emailed to taxes@azica.gov. However, the signature page must be
electronically signed and submitted.
Download Self Insured Annual Injury Report Excel File
(G) Total Claims $10,000 and over
0.00
Column C
Column D
Column E
Column F
Column G
Total Columns (C+D+E+F+G)
(I) Claims $1,999 or less Medical only
(If included here, do not include in Line J)
(J) Claims $9,999 or less Medical and/or Indemnity:
(K) Total all claims:
0.00
I certify this report is a true and complete for the period stated.
Submitter Email Address:
Officer Signature:
Alternative Email Address:
Officer Name:
Primary Phone Number:
Officer Title:
Alternative Phone Number:
Date of Officer Signature:
Fax Number:
Name and Title of Person completing this form if different than above:
TPA Name:
Date Form Submitted:
TPA Phone Number:
If there are any questions, please contact the Tax Accountant at 602-542-4654 or e-mail at Taxes@azica.gov
ACCOUNTING ICA 6611 – REV 12.5.19