Form HS-31-C 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-C ACCIDENT PREVENTION SERVICES ANNUAL REPORT 1) Insurance Company: 3) Mailing Address: 4) City, State, Zip: 2) Telephone no.: ( ) 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 8a) Number of Field Safety Representatives (FSRs) used by the insurance company: 8b) Number of Approved Professional Safety Sources (APSSs) used by the insurance company: 9) Number of on-site inspections performed by FSRs: 10) Identify the number of AR workers' 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: 11c) Total number of medical-only workers' compensation claims opened: 11d) Total amount paid on medical-only claims: 11e) Total number of indemnity claims opened: 11f) Total amount paid on indemnity 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 Company Representative (Print Name) Position or Title Date _________________________________________________ Designated Insurance Company Representative (Signature) Email Address ____________________________ 11a) Current Year (yyyy) 11b) Previous Year (yyyy) Contract HS-31-C American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Form AWCC HS-31-C Accident Prevention Services Annual Report This form must be filed with the Accident Prevention Services Section no later than April 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 Division, Arkansas Workers' Compensation Commission. Note: Complete one form for each company or sister company in the insurance group. A separate report must be submitted for each sister company. Email reports may be submitted as long as the report is scanned or photocopied with an original signature on it. Complete all blanks. Do not use "N/A" or "not applicable." Items 1-5: List name, address, telephone number, NAIC insurance company number and the NAIC group number for the insurance group of which the insurance company is a member This includes amounts spent for contract field service representatives, company field safety representatives, salaries and any related expenses, to include clerical-related expenses. Expenses or costs for underwriting visits to policyholders' premises shall not be included. 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. 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 7a and 7b are identical, attach an explanation. Enter the name and office of the person supplying the information for Items 7a and 7b. Enter the total number of Field Safety Representatives (FSRs) and Approved Professional Safety Sources (APSSs) utilized by the insurance company and indicate if they are employees of the insurance company or their services are under contract. "On-site" surveys do not include underwriting surveys for prospective accounts. Enter the number of Arkansas workers' compensation insurance policyholders in each category, based on written manual premium. Current Year (yyyy) format ­ Enter the year for the current reporting period. For example: the report submitted for the April 1, 2009 deadline, the current year would be 2008. Previous Year (yyyy) format ­ Enter the previous year to the current reporting period. For example: the report submitted for the April 1, 2009 deadline, the previous year would be 2007. Enter the total number of medical-only workers' compensation claims opened during the current year and the previous year in Arkansas. Enter the total amount paid on medical-only workers' compensation claims paid during the current year and the previous year in Arkansas. Enter the total number of indemnity workers' compensation claims opened during the current year and the previous year in Arkansas. Enter the total amount paid on indemnity workers' compensation claims paid during the current year and the previous year in Arkansas. Item 6: Item 7a: Item 7b: Item 7c: Item 8a/b: Item 9: Item 10: Item 11a: Item 11b: Item 11c: Item 11d: Item 11e: Item 11f: Authorized signature of insurance company's designated representative. Insert date the report was completed by the designated representative. American LegalNet, Inc. www.FormsWorkFlow.com