This report is subject to verification by ICA auditorsSELF INSURED NAME:PERIOD COVERED:To (fill in the bolded cells)Line 1Line 2Line 3Line 4Line 5Line 6Line 7Line 8-$ Line 9Line 10Line 11Line 12(not to exceed $12 annually per employee)Line 13Line 14-$ Line 15Line 16-$ Line 17Line 18Line 19-$ Officer Signature: Officer Name: Officer Title: Date of Officer Signature: Date Form : Email Address:Alternative Email Address:FAX Number:Primary Phone Number:Alternative Phone Number:If there are any questions, please contact the Tax Accountant at 602-542-4654 or e-mail at Taxes@azica.govOut-patient care revenueTotal Revenue (total of lines 9, 10, 11, 12 & 13) Miscellaneous revenue Employee paid workers' compensation premiums pursuant to A.R.S. 247 23-1070 Employer paid workers' compensation premium refunds & excess insurance reimbursementsPharmacyThird Party Administrator fees (if care is self-administered include staff adjuster payroll)Licenses and taxesMiscellaneous medical supplies, outsourced services, nurse case mgmt. & admin. expensesUtilities, rent or mortgage (Plan B only) Cash balance at beginning of year. Total cash available (total of lines 14 and 15) Investments earnings (annual)Operating expenses (deduct lines 1 through 8)Other disbursements (deduct) Section B - REVENUE AND CASH FLOW - Plan B only Charges for services:Total Operating Expenses (total of lines 1, 2, 3, 4, 5, 6, 7 & 8)Expenses related to medical claims (including taxes, excess insurance, etc.)Surgeon's and Physicians' fees (not included in staff payroll) Section A - OPERATING EXPENSES Payroll for medical staff (Plan B only)I certify this report is a true and complete account of Operating expenses, revenue and cash flow, and net cash balances for the period stated.Name & Title of Person completing form if different from above:Net cash balance at end of year (line 16 less lines 17, 18 and 19) Self-Insured Employers on Plan B and employers who direct medical care pursuant to A.R.S. 247 23-1070 In-patient care revenue American LegalNet, Inc. www.FormsWorkFlow.com