Workers' Compensation ICA SI Liability Form 11-1-2021

Workers’ Comp Liability Form  - Revised 11/8/2011 
                         INDUSTRIAL COMMISSION OF ARIZONA                
 
WORKERS’ COMPENSATION LIABILITY FORM 
 
1. NAME OF SELF-INSURER: ________________________________________________________ 
 
2. EMPLOYEE COUNT ______________ Total Employee Count from prior anniversary date to current 
(W-2 count to include all full & part time employees that worked regardless of whether or not they are 
still employed). Explain decrease from prior year on separate cover. 
 
3. SECURITY DEPOSIT CALCULATION 
          (Number of Claims, Incurred Liability and Paid amounts must be calculated from the 
           Effective Date of Self-Insurance Authority to the present date): 
 
    A                   B                  C               D                   E               F 
  G  
      H 
Total 
Amount 
of 
Open  
Claims 
Incurred 
 Medical 
    Paid 
Medical 
Total 
Medical 
Owed 
(B – C = D) 
Incurred 
  Comp. 
    Paid 
  Comp. 
Total  
Comp. 
Owed 
(E – F = G) 
  TOTAL  
     ALL  
 CLAIMS 
(D + G = H) 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total Owed from Column H:                                                                                              $_______________ 
 
Excess insurance reimbursement amount expected:  
 
 
 
            $_______________ 
 
Net remaining liability: 
 
 
 
 
 
 
 
            $_______________ 
 
Multiply by 125%:                                                                                                                  $_______________ 
 
Calculated Security Deposit: (minimum security deposit $100,000.00)              
            $_______________ 
 
 
4. Name of Excess Insurance Carriers providing reimbursement: (provide detailed report with carrier 
name, SIR amount, claimant names, DOI and claim number, reimbursement amount requested) 
        
        (List the Policy Year(s) of Reimbursement taken)  _________________________________________________ 
 
I, ____________________________ attest that there is no affiliate relationship between the self-
insurer and the excess insurance carrier and to the truthfulness of the above information. 
 
Self-Insurers Authorized Representative Signature: ____________________________________________ 
 
 
 
 
                 Printed Name/Title:  ____________________________________________ 
 
 
 
 
 
 
 
  
DATE: _____________________         * Must be signed by Designated Officer 
City of Glendale
2217
171
$12,938,436.
67 
$7,446,772.15 $5,491,664.52 $10,047,368.
44 
$3,183,582.3
2 
$6,863,786.12 
 
$12,355,450.64 
12,355,450.64
4,846,105.84
7,509,344.80
9,386,681.00
9,386,681.00
07/01/2019, 07/01/2004, 07/01/2017, 07/01/1994, 07/01/2011, 07/01/2009, 07/01/2018, 07/01/2000
Lisette Camacho
SIGN
Lisette Camacho, Director, Budget & Finance