COURT DIVISION OF WORKERS' COMPENSATION COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. Premium Cost Containment Program : Index No. REQUEST FOR CERTIFICATION : : Calendar No. Employer Name: Employer FEIN: Employer Mailing Address: Employer City, State, ZIP: Name of Insurance Carrier: Policy Number: Date Program Was Implemented: ____________________________________________________________ JUDICIAL SUBPOENA Plaintiff(s) ____________________________________________________________ -against: ____________________________________________________________ ____________________________________________________________ : ____________________________________________________________ : : ____________________________________________________________ Defendant(s) . ........ ............................. Nature of. Business:. . . . . . . . . . . . . . . ____________________________________________________________ ____________________________________________________________ To obtain certification status in the Colorado Workers' Compensation Premium Cost Containment Program, it THE PEOPLE OF THE STATE OF NEW YORK must be demonstrated that the applicant employer has actively followed an approved loss prevention and loss TO 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. GREETINGS: THE APPLICANT EMPLOYER MUST PROVIDE THE DIVISION WITH DOCUMENTATION OF THE FOLLOWING COST CONTAINMENT PROGRAM REQUIREMENTS 1. 2. 3. 4. 5. b. The safety and health of all employees are a top priority. Formal Creation of a Safety Committee or Coordinator (enclose signed and dated documentation). a. Committee or coordinator has clearly defined tasks and objectives. Your failure to comply policies and objectives. b. Discuss/recommend safetywith this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a c. Identify unsafe conditions and practices. result of your failure to comply. d. Investigate all accidents. e. Conduct safety committee meetings and promote safety awareness. Witness, , one of the Justices of the f. Establish and Honorable update safety rules. Court in County, day of , 20 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. (Attorney must sign above and type name below) c. Safety rules are applicable and updated as needed. All Employees Undergo Safety Awareness and Loss Prevention Training (enclose signed and dated Attorney(s) for 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. Written Designation of a Medical Provider (enclose a signed and dated copy). Office and P.O. Address 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 Telephone No.: concerning the designated medical provider. Facsimile No.: E-Mail Address: Mobile Tel. No.: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before the Honorable Court Formal Declaration of an Organization-wide Lossat the Prevention and Loss Control Policy (enclose a signed and , located at County of dated copy). , on the day of , 20 , at o'clock in the noon, and at any recessed a. in room policy reflects the philosophy of top management. The or adjourned date, to testify and give evidence as a witness in this action on the part of the WC109 Rev 05/05 Page 1 of 3 American LegalNet, Inc. www.USCourtForms.com I 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). 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 Effective Date Expiration Date No. Of Injuries During Policy Period Total Costs Incurred on All Claims During Policy Period Total Employee Hours Worked During Policy Period 7. 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. An on-site evaluation of the employer's Cost Containment Program may be conducted. NOTE: 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 E-mail Address ______________________________________ ______________________________________ _________________________________________________ Type or Print Name of Contact Person Contact Person's Telephone Number __________________________________________