Request For Certification {WC109}

WC109 - REQUEST FOR CERTIFICATION. This form is used by employers in Colorado to apply for certification in the Workers' Compensation Premium Cost Containment Program. This program aims to recognize employers who have implemented an effective loss prevention and control program, helping to reduce workers' compensation costs. To qualify for certification, the employer must demonstrate that they have followed an approved loss prevention strategy for at least one year. The form requires employers to submit various documents, including a formal loss prevention policy, proof of safety training for employees, a safety committee or coordinator, a designated medical provider, and written policies for claims management. The form also requests a summary of injury data and costs from the last three policy periods, along with currently valued loss reports from the employer's insurance carrier. Employers must provide signed verifications and documentation supporting their adherence to these program requirements. An on-site evaluation may be conducted as part of the certification process, and the employer's insurance carrier may be contacted for additional information. The completed form, along with all necessary attachments, must be returned to the Colorado Division of Workers' Compensation to be processed. www.FormsWorkflow.com