SIGNED WORKERS' COMPENSATION LIABILITY FORM (FILLABLE).PDF

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
                 
Maricopa County
13,746
352
21,617,55
1
16,329,368
5,288,183
25,070,27
8
8,679,284
16,390,994
21,679,177
21,679,177
2,267,108
19,412,069
24,265,086
24,265,086
See attached Loss and Excess Credit Worksheet
Cynthia Goelz
SIGN
Cynthia Goelz, Chief Financial Officer
11/12/2021