Voluntary Drug-Free Workplace Programs VDFWP Annual Insurance Carrier Report
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Voluntary Drug-Free Workplace Programs VDFWP Annual Insurance Carrier Report Form. This is a Arkansas form and can be use in Workers Comp.
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Tags: Voluntary Drug-Free Workplace Programs VDFWP Annual Insurance Carrier Report, HS-36-B, Arkansas Workers Comp,
ARKANSAS WORKERS’ COMPENSATION COMMISSION
Form HS-36-B
HS36-B
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
Ark. Code Ann.
§11-14-101 & AWCC
Rule 36
Voluntary Drug-Free Workplace Program (VDFWP)
Annual Insurance Carrier Report
Carrier Information
1) Insurance Carrier:
2) Address:
3) City:
4) State:
5) Zip:
6) NA IC Ca rrier Identific ation No .:
8) Con tact:
7) NA IC Insu rance G roup N o.:
9) Telephone: (
)
10) e-M ail:
Client Information
Please complete the following information for each client awarded premium credits for the most recent calendar year for its Voluntary
Drug-Free Workplace Program (VDFWP)
Client Name
Address
Did the insurance
company audit the
client’s VDFWP
Yes
No
Briefly note any assistance
provided to the client by
the insura nce com pany in
either implementing or
maintaining its VDFWP
I certify that the above information is correct to, the best of my knowledge, and I have read and understand the provisions of Ark. Code
Ann. §11-14-101 & AWCC Rule 36.
__________________________________________________________ ____________________________
Designated Insurance Company Representative
Position o r Title
________________
Date
HS-36-B
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