ARKANSAS WORKERS’ COMPENSATION COMMISSION Form HS-31-D HS31-D 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 Worksheet 1a) Policyholder’s name: 1b) Arkansas location(s): 1c) Effective date (mm/dd/yyyy): 2a) NAIC Code: 2b) Number of employees: 2c) Best Hazard Index: 3) Insurance Carrier: Current policy year First prior year Second prior year 4) Number of claims 5) Frequency indicator 6) Loss ratio 7) Number of contacts 8a) Date of last contact (mm/dd/yyyy): 8b) Experience modifier: 9a) Written manual premium (unadjusted): $ 9b) Direct premium written (adjusted): $ Note: May Attach Additional Sheets, if needed. 10) Description of operations: 11) Attach trend analysis for the last three years, by year: 12) Describe any planned, programmed or scheduled service for this policyholder: 13) Describe training program review and provide a list of recommendations made: 14) Were accident analysis services provided? ‘ Yes 15) Were industrial hygiene/health service s provided? ‘ No ‘ Yes ‘Not Needed ‘ No ‘Not Needed 16) Comments: 17a) Completed by (print name and title, sign): 17b) Date: (Form instructions on back side) HS-31-D American LegalNet, Inc. www.FormsWorkflow.com Instructions for Completing Accident Prevention Services Worksheet AWC C-HS-31-D (Rev. x-x-2007) This form may be obtained from the Accident Prevention Services Program of the Health and Safety Division. 1a. 1b. 1c. 2a. 2b. 2c. 3. 4. Name o f policyholder (e.g., “ABC Com pany”). Each Arkansas location (by city). Date of annual renewal. If account is a new policy, include policy inception date. North American Industrial Classification System code (NAICS; - 5 digits, e.g. 21233) Num ber of covered em ployees. Hazard index acco rding to A.M . Best Compa ny. Name o f insuranc e com pany. If the insurance comp any is a sub sidiary comp any, enter pare nt com pany. Number of claims in the current policy year to date (See item 17b) followed by the total number of claims made each of the two prior policy years. 5. Frequency indicator = 6. Loss ratio = Incurred Losses X 100 W ritten Manua l Premium Number of Claims X 100 Number of Employees 7. Number of on-site contacts with the acco unt made by the Field Safety Representative(s) in the current policy year to date (see item 17b ) followed by the total number o f contacts mad e each of the two prior po licy years. 8a. Date of last contact or direct communication with the account by the Field Safety Representative. 8b. Experience mod ifier. 9a. W ritten manual premium for current policy year. If policy is a retrospective, cost plus or self-rating plan, enter your best estimate of the annual premium. Contact your carrier’s tax department for assistance. 9b. Direct premium written (adjusted) for current policy year. 10. Enter the po licyhold er’s type of business. Include a description of the kinds of o perations invo lved as well as their size (e.g., “W ire good s manufacturing. B ulk rolls of coiled wire and sheet metal are cut to size, weld ed and painted or plated. Insured has 3 locations and 12 vehicles.”). 11. Attach a trend a nalysis/loss run for each of the last three years. 12. Describe any programmed, planned or scheduled service that has been established for this policyholder, including type of service, frequency, etc. 13. Describe the training programs emp loyed by the p olicyho lder. List training progra ms rec omm ended by the Field Safety Representative(s). Tell whether they have been implemented by the policyholder and, if so, how. 14. State whether accidents were of sufficient number to warrant an analysis to ide ntify trends. If yes, briefly describe analysis results provided to the policyholder. 15. State whether the policyholder’s operations required industrial hygiene/health service. If yes, describe what services were provided by the insurance carrier. 16. Comm ent on response/receptiveness of policyholder to recommendation(s) by Field Safety Representative(s). 17a . Nam e and title (printed ) and signature of person comp leting this wo rkshee t. 17b. Date worksheet was completed. HS-31-D American LegalNet, Inc. www.FormsWorkflow.com