ARKANSAS WORKERS’ COMPENSATION COMMISSION Form H S-31-C HS31-C 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. §11-9-409 & AWC C Rule 31 Rev. 1-1-2008 ACCIDENT PREVENTION SERVICES ANNUAL REPORT 1) Insu rance Compa ny: 2) Telephone no.: ( 3) M ailing Address: 4) City, State, Zip: ) 5a) NAIC Company no.: ____________________ 5b) NAIC Group no.: ____________________ 6) Total amount spent for accident prevention services during the current calendar year (salaries, travel): $___________________ 7a) Total amount of workers’ compensation insurance written manual premium in AR for year: $________________________ 7b) Total amount of workers’ compensation insurance direct premium written in AR for year: $__________________________ 7c) Premium information provided by: Name: _____________________________ Office: _______________________________ Employee Contract 8a) N umb er of Field Sa fety Rep resentatives(F SRs) used by the insu rance com pany: 8b) Num ber o f App roved Professio nal Safety Sources (A PSSs) used by the insurance co mpa ny: 9) Nu mber o f on-site inspections perform ed by FS Rs: 10) Identify the number of AR wo rkers’ compensation insurance policyholders for the most recent calendar year for the premium groups listed: _____ $0 - $24,999 _____ $25,000 - $49,999 _____ $50,000 - $74,999 _____ $75,000 - $100,000 _____ Above $100,000 Evidence of accident prevention effectiveness will be measured by an analysis of the following loss data: Current Year Previous Year 11a) Total number of medical-only workers’ compensation claims opened: 11b) Total amount pa id on medical-only claims: 11c) Total number of indemnity claims opened: 11d) Total amount pa id on indem nity claims: I certify that the above information is correct to the best of my knowledge and I have read and understand the provisions set by Arkansas Code Ann. §11-9-409. _______________________________________________ Designated Insurance C omp any Representative (Print Nam e) ________________________________ Position o r Title ______________________ Date _________________________________________________ Designated Insurance Company Re presentative (Signature) HS -31-C American LegalNet, Inc. www.FormsWorkflow.com Instructions for Comp leting Form A W CC HS-3 1-C Accident Prevention Services Annual Report This form must be filed with the Acciden t Pre vention S ervices Se ction no later than A pril 1 of each year. Calendar year is defined as January 1 - December 31. This form may be obtained from the Accident Prevention Services Section of the Health and Safety D ivision, A rkansa s W orkers’ Compe nsation Commission. Note: Com plete one form for each company or sister company in the insurance group. Return the original (copies are not acceptable). A sep arate re port must be submitted for eac h sister co mpa ny. Comple te all blanks. Do not use “N/A ” or “not applicab le.” Items 1-5: List name, address, telephone number, NAIC insurance comp any number and the NAIC group number for the insurance group of which the insurance company is a member. Item 6: This includes amounts sp ent for contract field service represe ntatives, compa ny field safety representatives, salaries and any related expenses, to include clerical-related expe nses. Expenses or costs for und erwriting visits to policyholders’ premises shall not be included. Item 7a: Enter the total amount of workers’ compensation insurance written manual premium, less expense constant, for calendar year. See Ark. Code Ann. §11-9-303. Check with your carrier’s tax department for help. Item 7b: Enter the total amount of workers’ compensation insurance direct premium written for calendar year. If the amount on line 7b is larger than that on line 7a, or lines 7 a and 7b are identical, attach an explana tion. Item 7c: Enter the nam e and office of the person supplying the informatio n for Item s 7a and 7b. Item 8: Enter the total number of Field Safety Representatives (FSRs) and App roved Professiona l Safety Sources (A PSS s) utilized by the insurance company and indicate if they are employees of the insurance company or their services are under contract. Item 9: “On-site” surveys do not include und erwriting surveys for prosp ective accounts. Item 10: Enter the number of Arkansas workers’ compensation insurance policyholders in each category, based on written manual prem ium.. Item 11a: Enter the total number of medical-only workers’ compensation claims opened during the current year and the previous year in Arkansas. Item 11b: Enter the total amount paid on med ical-only workers’ compensation claims paid during the current year and the previous year in Arkansas. Item 11c: Enter the total number of indemnity workers’ compensation claims opened d uring the current year and the previous year in Arkansas. Item 11d: Enter the total amount paid on indemnity workers’ compensation claims paid during the current year and the previous year in Arkansas. Authorized signature of insurance company’s designated representative. Insert date the report was completed by the designated representative. HS -31-C American LegalNet, Inc. www.FormsWorkflow.com