INDUSTRIAL COMMISSION OF ARIZONA SELF-INSURER’S QUARTERLY ADMINISTRATIVE AND SPECIAL FUND TAX FORM 103 FOR 2009 FROM: March 30, 2009 DUE April 30, 2009 June 30, 2009 DUE July 31, 2009 September 30, 2009 DUE October 31, 2009 December 30, 2009 DUE January 31, 2010 Self-Insured Name Street Address City State Zip code COMPUTATION OF QUARTERLY TAXES Insurers who were required to pay an Administrative Fund tax of at least $2,000 for the preceding calendar year must file this report and pay the taxes calculated for the current calendar year. A.R.S. § 23.961(L) A. Method I ADMINISTRATIVE FUND A.R.S.§ 23-961 (K) 1 2008 Net Taxable Premium (Reference Form 100, Line A or Form 101, Line 1) LINE A1 $ 2 Administrative tax - Multiply Line 1 by 3.00% or .030 LINE A2 $ A.R.S. § 23-961 (K) 3 Multiply Line 2 by 25.0% or 0.25 LINE A3 $ 4 Special Fund tax - Multiply line 1 by 1.50% or .015 A.R.S. § 23-1065 (A) LINE A4 $ 5 Multiply Line 4 by 25.0% or 0.25 LINE A5 $ 6 Amount Paid (Add lines A3 & A5 together and pay this amount) LINE A6 $ B. Method II This method will be based on actual payroll, by Workers’ Compensation Code, losses for the applicable quarter. If this method is selected, please contact us to obtain the necessary forms. Penalty and interest will be assessed for failing to pay the tax on time: The greater of twenty-five dollars or five percent of the tax due plus interest at the rate of one percent per month from the date the tax was due, which is 30 days after close of the quarter. A.R.S. § 23-961 (N) Please return the COMPLETED FORM with your check payable to Industrial Commission of Arizona for the total payment due and mail to: Industrial Commission of Arizona Attention: Tax Accountant 800 West Washington Street, Suite 301 Phoenix, Arizona 85007 If there are any questions, please contact the Tax Accountant at 602-542-1836 or e-mail at taxes@ica.state.az.us I certify that the foregoing is correct to the best of my knowledge and belief: (please complete all of the information) Officer Signature:________________________________________________Primary Email Address: Name: Title: Alternative Email Address: FAX Number: Primary Phone Number: Date of Officer Signature:__________________________________________ Name and Title of Person completing form if different than above: Alternative Phone Number: Alternative Phone Number: Name and Title of Person completing form (listed below): Date Form Completed:____________________________________________ American LegalNet, Inc. www.FormsWorkflow.com