Fill and Sign the Request for Certification for Workers Compensation Colorado Form

DIVISION OF WORKERS’ COMPENSATION Premium Cost Containment Program REQUEST FOR CERTIFICATION Employer Name: ____________________________________________________________ Employer FEIN: ____________________________________________________________ Employer Mailing Address: ____________________________________________________________ Employer City, State, ZIP: ____________________________________________________________ Name of Insurance Carrier: ____________________________________________________________ Policy Number: ____________________________________________________________ Nature of Business: ____________________________________________________________ Date Program Was Implemented: ____________________________________________________________ To obtain certification status in the Colorado Workers’ Compensation Premium Cost Containment Program, it must be demonstrated that the applicant employer has actively followed an approved loss prevention and loss control program for a period of at least one year. Copies of loss prevention documentation clearly showing compliance with each of the following requirements has been in effect for at least one year , must accompany this Request for Certification. THE APPLICANT EMPLOYER MUST PROVIDE THE DIVISION WITH DOCUMENTATION OF THE FOLLOWING COST CONTAINMENT PROGRAM REQUIREMENTS 1. Formal Declaration of an Organization-wide Loss Prevention and Loss Control Policy (enclose a signed and dated copy). a. The policy reflects the philosophy of top management. b. The safety and health of all employees are a top priority. 2. Formal Creation of a Safety Committee or Coordinator (enclose signed and dated documentation). a. Committee or coordinator has clearly defined tasks and objectives. b. Discuss/recommend safety policies and objectives. c. Identify unsafe conditions and practices. d. Investigate all accidents. e. Conduct safety committee meetings and promote safety awareness. f. Establish and update safety rules. 3. Clearly Defined and Conspicuously Posted Safety/Loss Prevention Rules (enclose a signed and dated copy). a. Hazards are identified and accident prevention rules are clearly communicated. b. All employees are made aware of the safety rules. c. Safety rules are applicable and updated as needed. 4. All Employees Undergo Safety Awareness and Loss Prevention Training (enclose signed and dated verification of employee safety training). a. The supervisor has provided and documented individual job/task safety training. b. Ongoing safety meetings are held for all employees and attendance (employee sign-off) recorded. 5. Written Designation of a Medical Provider (enclose a signed and dated copy). a. Provider is knowledgeable of fee schedules and agrees to honor designated provider agreements. b. Provider communicates with the employer on issues such as case management and modified duty. c. Employer will keep in contact with the injured worker and will inform employees on matters concerning the designated medical provider. WC109 Rev 05/05 Page 1 of 3 6. Written Policies and Procedures on Claims Management (enclose a signed and dated copy). a. Employer has investigated all incidents for third-party potential (enclose a completed investigation). b. Employer ensures that the insurance carrier is contacted in a timely manner and confirms that the employee was working at the time of the accident. c. Employer coordinates with the insurance carrier (at least annually) on issues such as loss runs review, outstanding reserves, and employee classification. d. Employer, when practicable, institutes a modified duty program in conformance with the attending physician’s restrictions (enclose modified duty documentation). 7. Use the following chart to provide a summary for EACH of the last three full policy periods , and the current policy year-to-date of your organization’s injuries, costs, and total employee hours worked. This information MUST be provided by POLICY period. Information should be taken from insurance carrier loss reports and payroll records. Read the attached instructions before completing . Policy Period No. Of Injuries During Policy Period Total Costs Incurred on All Claims During Policy Period Total Employee Hours Worked During Policy PeriodEffective Date Expiration Date 8. A currently valued copy (valued no more than 30 days prior to the date of application) of your insurance carrier’s detailed, gross loss reports for the last three full policy years, and the current policy year-to-date MUST be included with this request for certification. Read the attached instructions for further information . NOTE : An on-site evaluation of the employer’s Cost Containment Program may be conducted . By signing this request, the contact person affirms that the above requirements have been met and acknowledges the Premium Cost Containment Program may contact the applicant employer’s workers’ compensation insurance carrier to obtain information relative to this request. _________________________________________________ Signature of Contact Person ______________________________________ Date of Signature _________________________________________________ Type or Print Name of Contact Person ______________________________________ E-mail Address ( ) ___________________________________________ Contact Person’s Telephone Number ( ) _____________________________________ Fax Number PLEASE RETURN THE COMPLETED FORM CONTAINING THE ORIGINAL SIGNATURE OF THE CONTACT PERSON. ATTACH ALL REQUIRED DOCUMENTATION. Premium Cost Containment Program Board Division of Workers’ Compensation 633 17th St., Suite 400 Denver, CO 80202-3660 WC109 Rev05/05 Page 2 of 3 INSTRUCTIONS FOR COMPLETING ITEMS 7 & 8 Please read before completing Request for Certification form. ITEM 7 - Summary Chart 1) Policy Period is defined as the policy year or partial policy year reflected on loss reports. These periods might not coincide with the calendar year. DO NOT convert policy periods to calendar years (i.e., If policy period is shown on loss reports as July 1 - June 30, the policy period should be reported as shown). 2) Number of Injuries is defined as the number of claims reported to your insurance carrier. In some cases, this will include reports of injuries that have incurred no costs. ( All injuries should be reported to your carrier, regardless of severity ). OSHA reporting requirements are not a consideration. 3) Total Costs on All Claims is defined as the gross incurred amount, and includes both paid and outstanding reserve amounts. This includes medical costs, indemnity costs, and miscellaneous expenses. Deductible amounts paid by the insured employer must also be included in this figure. 4) Total Employee Hours Worked is defined as the total number of hours worked by all employees during each indicated policy period. There is no need to break this figure down into "regular" and "overtime" hours, nor is it necessary to differentiate between "exempt" and "nonexempt" employee hours. Hours MUST NOT be extended beyond the valuation date of loss reports (i.e., if loss reports are valued as of June 30, hours worked should be reported only through June 30 even though the date of the application may be July 20). ITEM 8 - Loss Reports Currently Valued loss reports from your insurance carrier covering the last three full policy periods and the current policy year-to-date must accompany all requests for certification or recertification. In order to be currently valued, ALL loss reports must have been printed within thirty days of the date of application. Only actual detailed, gross valuation loss reports are acceptable. On-line printouts, summary loss reports and loss reports that do not include deductible amounts are unacceptable for program purposes. Summaries prepared by agents or brokers and in-house accounting program printouts are generally not acceptable. Original signatures are required. Failure to properly complete this request form or provide the required loss reports will delay the processing of your request. If you have any questions, please contact the Premium Cost Containment Program 303.318.8644 WC109 Rev 05/05 Page 3 of 3