Accident Prevention Services Worksheet {HS-31-D}

Form HS-31-D Ark. Code Ann. §119-409 & AWCC Rule 31 Rev. 7-1-2010 ARKANSAS WORKERS' COMPENSATION COMMISSION HEALTH & SAFETY DIVISION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 HS31-D Accident Prevention Services Worksheet 1a) Policyholder's name: 1b) Arkansas location(s): 1c) Last Policy Effective date (mm/dd/yyyy) 2a) NAICS no. : 2b) Number of employees: 2c) Best Hazard Index: 3) Insurance Carrier : Current policy year ____ - ____ (yy) 4) Number of claims 5) Frequency indicator 6) Loss ratio 7) Number of contacts 8a) Date of last contact (mm/dd/yyyy): 9a) Written manual premium (unadjusted): $ 8b) Experience modifier: 9b) Direct premium written (adjusted): $ (yy) First prior year ____ - ____ (yy) (yy) Second prior year ____ - ____ (yy) (yy) Note: May Attach Additional Sheets, if needed. 10) Description of operations: 11) Attach trend analysis for the last three years, by year: 12) Describe any planned, programmed or scheduled service for this policyholder: 13) Describe training program review and provide a list of recommendations made: 14) Were accident analysis services provided? ` Yes ` No `Not Needed 15) Were industrial hygiene/health services provided? ` Yes ` No `Not Needed 16) Comments: 17a) Completed by (print name and title, sign): 17b) Date: 17c) Email Address (Form instructions on back side) HS-31-D American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Accident Prevention Services Worksheet AWCC-HS-31-D (Rev. 01-01-08) This form may be obtained from the Accident Prevention Services Program of the Health and Safety Division. Name of policyholder (e.g., "ABC Company"). Each Arkansas location (by physical address) Date of last annual renewal. If account is a new policy, include policy inception date. North American Industrial Classification System code. (NAICS Number: NOT SIC Code number) Number of covered employees. Hazard index according to A.M. Best Company. Name of insurance company. If the insurance company is a subsidiary company, enter parent company. Number of claims in the current policy year to date (See item 17b) followed by the total number of claims made each of the two prior policy years. 5. Frequency indicator = Number of Claims X 100 Number of Employees 6. Loss ratio = Incurred Losses X 100 Written Manual Premium 7. Number of contacts with the account made by the Field Safety Representative(s) in the current policy year to date (see item 17b) followed by the total number of contacts made each of the two prior policy years. 8a. Date of last contact or direct communication with the account by the Field Safety Representative. 8b. Experience modifier. 9a. Written manual premium (unadjusted) for current policy year. If policy is a retrospective, cost plus or self-rating plan, enter your best estimate of the annual premium. Contact your carrier's tax department for assistance. 9b. Direct premium written (adjusted) for current policy year. 10. Enter the policyholder's type of business. Include a description of the kinds of operations involved as well as their size (e.g., "Wire goods manufacturing. Bulk rolls of coiled wire and sheet metal are cut to size, welded and painted or plated. Insured has 3 locations and 12 vehicles.") 11. Attach a trend analysis/loss run for each of the last three years. 12. Describe any programmed, planned or scheduled service that has been established for this policyholder, including type of service, frequency, etc. 13. Describe the training programs employed by the policyholder. List training programs recommended by the Field Safety Representative(s). Tell whether they have been implemented by the policyholder and, if so, how. 14. State whether accidents were of sufficient number to warrant an analysis to identify trends. If yes, briefly describe analysis results provided to the policyholder. 15. State whether the policyholder's operations required industrial hygiene/health service. If yes, describe what services were provided by the insurance carrier. 16. Comment on response/receptiveness of policyholder to recommendation(s) by Field Safety Representative(s). 17a. Name and title (printed) and signature of person completing this worksheet. 17b. Date worksheet was completed. 17c. Email address 1a. 1b. 1c. 2a. 2b. 2c. 3. 4. HS-31-D American LegalNet, Inc. www.FormsWorkFlow.com