WSP-45 (01-19) AI Section 287.123, RSMo, requires all insurance carriers writing workers222 compensation insurance in the state of Missouri to establish a program to provide comprehensive safety engineering and management services to their Missouri insureds upon request. Each carrier must submit a written outline of its program to the Missouri Workers222 Safety Program for certification. Re-certification is required annually to determine MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS MISSOURI WORKERS222 SAFETY PROGRAM APPLICATION FOR ANNUAL CERTIFICATION Safety Engineering & Management Program P.O. Box 58 Jefferson City, MO 65102- 0058 573-526- 5757 www.labor.mo.gov/DWC I.INSURANCE CARRIER INFORMATION NAME OF INSURANCE GR OUP (PARENT COMPANY) NAIC # STREET ADDRESS CITY STATE ZIP PHONE FAX WEBSITE List the names and NAIC numbers of all subsidiary companies in your group that are authorized to write workers222 compensation insurance in Missouri and will operate under your certified safety program. SUBSIDIARY NAIC # SUBSIDIARY NAIC # SUBSIDIARY NAIC # SUBSIDIARY NAIC # SUBSIDIARY NAIC # II.CONTACT PERSON List the name and contact information of the person designated and appointed responsible for the initiation and management of the carrier222s certified safety program. This person is to be the official contact for your organization.NAME OF CONTACT PERS ON TITLE STREET ADDRESS CITY STATE ZIP PHONE E - MAIL American LegalNet, Inc. www.FormsWorkFlow.com WSP-45-2 (01-19) AI List additional personnel, if any, on supplemental page. List additional TPAs, if any, on supplemental page. III. LOSS CONTROL PERSONNEL Provide a list of all loss control field personnel employed by your company who will provide loss control services to your Missouri insureds. Indicate whether they are currently certified as consultants or engineers by the Missouri Workers222 Safety Program. If not, provide a description of their qualifications to provide these services (education, training, certifications, experience, etc.) on a supplemental page or check Seeking C ertification and include an Application for Certification Safety Consultant/Engineer with this application. NONE Currently certified by the Missouri Workers222 Safety Program as a consultant or engineer? NAME TITLE PHONE Yes No Seeking Certification NAME TITL E PHONE Yes No Seeking Certification NAME TITLE PHONE Yes No Seeking Certification NAME TITLE PHONE Yes No Seeking Certification NAME TITL E PHONE Yes No Seeking Certification IV. THIRD PARTY ADMINISTRATORS List all third- party administrators and/or outsource companies you will contract with to provide loss control services to your Missouri insureds. On a supplemental page, p rovide a description of how you assessed their qualifications to provide these services, such as having consultants certified by the Missouri Workers222 Safety Program. Describe how these services will be monitored to ensure they meet t he needs of your Missouri insureds. NONE BUSINESS NAME ADDRESS CONTACT NAME PHONE E - MAIL BUSINESS NAME ADDRESS CONTACT NAME PHONE E - MAIL BUSINESS NAME ADDRESS CONTACT NAME PHONE E - MAIL American LegalNet, Inc. www.FormsWorkFlow.com WSP-45-3 (01-19) AI This section must be completed by carriers seeking initial certification. Carriers seeking re-certification may skip to the Annual Report, unless a full outline has been requested by the Missouri Workers222 Safety Program. Provide the following information on a supplemental page. A. Briefly describe the process you will use to provide requested loss control service. Include time frames and whether you will provide in-house assistance or utilize outside sources. B. Provide a description of the method you will use to assist your insureds in the recognition of workplace safety/health hazards and make recommendations to correct identified hazards. How will you assist in conducting accident investigations? How will you assist in developing and reviewing their written programs? C. Describe how you will measure the effectiveness of your loss control efforts with individual Missouri insureds. This includes how you manage the collection of information relating to worker safety, the effect of the program on the employer222s injury and occupational disease incidence rates, and the severity of injuries that do occur. Be aware that as part of your annual renewal, the Missouri Workers222 Safety Program may request that you provide specific data on the effect your program has had with individual insureds. D. Describe how the effectiveness of your loss control efforts will be communicated to assist Missouri insureds. E. Describe the process, including time frames, you will use to respond to a request for service from one of your Missouri insureds. F. Briefly describe your company222s policy regarding non-compliance to recommendations made to an insured to improve safe work practices, policies, or procedures, or to mitigate identified workplace hazards. G. What measures will your company take to ensure your safety program is kept current with industry standards to provide accurate information on newly identified occupational safety/health hazards and updates on existing hazards? H. Provide an example of the method you will use to inform your insureds of the loss control services available to them through your program. This must be done at initial purchase of a policy and annually thereafter. This section must be completed by each carrier as part of their annual re-certification. It is not required for carriers completing an initial application. Provide the following information on a supplemental page. The information requested must be provided for the previous calendar year. A. Indicate the total amount of Missouri written workers222 compensation premiums your group/company reported to the NAIC (actual or estimated). B. Provide a list of all changes made to your Missouri certified program in the past year. Use the Program Outline Requirements for guidance. C. Based on your experiences with your Missouri insureds, which safety and health topics do you feel will need the most attention in the coming year? Are there areas where you feel the safety and health community needs to focus additional development or research efforts? Briefly explain the reasoning behind your answers. V. SAFETY ENGINEERING & MANAGEMENT PROGRAM OUTLINE REQUIREMENTS VI. ANNUAL REPORT American LegalNet, Inc. www.FormsWorkFlow.com WSP-45-4 (01-19) AI D. Provide copies of two reports of safety services that were provided to separate Missouri employers. These should be reports of services provided, not underwriting surveys. E. Provide a list of all Missouri employers who received service under your Missouri certified safety program. This includes any service or assistance provided for the purpose of evaluating, developing, implementing, or enhancing the safety and health program of a Missouri employer at the request of that employer. This does not include providing answers to simple questions by phone, fax, or e-mail. Provide the following information in a spreadsheet: Business name Address Name of contact person Telephone number of contact person Premium level o Premium may be reported in one of the following ranges A. $0 to $3,500 B. $3,501 to $10,000 C. $10,001 to $50,000 D. $50,001 or higher Current experience modifier rate Most recent date of service Experience modifier rate at time of service A. Complete the attached survey on the safety and health programs available to your insureds. Missouri Division of Workers222 Compensation is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. VII. PROGRAMS SURVEY VIII. AUTHORIZED SIGNATURE The undersigned acknowledges understanding of RSMo 287.123, the associated rule 8 CSR 50-7, and that all submitted material is accurate and complete. AUTHORIZED SIGNATURE DATE American LegalNet, Inc. www.FormsWorkFlow.com