INDUSTRIAL COMMISSION OF ARIZONA NOTICE OF SELF-INSURER’S TERMINATION OF SELF-INSURANCE FORM 1. Name, address and telephone number of self-insurer: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2. Name, address and telephone number of all Arizona subsidiaries and/or operations (if necessary, attach supplement sheets): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 3. Names and addresses of all partners, if self-insurer is a partnership: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 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: ____________________ Notice of Self-Insurer’s Term of S.I. Form 1 American LegalNet, Inc. www.USCourtForms.com 6. Name and address of workers’ compensation insurance carrier providing coverage after the effective date of termination: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 7. For the new coverage; effective date of workers’ compensation coverage: __________________________________________________________________ 8. Location of claim files occurring during the period of self-insurance: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ I attest to the correctness of the above information. ______________________________ (authorized signature) Title: _________________________ Phone number: _________________ Notice of Self-Insurer’s Term of S.I. Form 2 American LegalNet, Inc. www.USCourtForms.com