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Self Insured Trust Safety Program Initial Certification Procedures Form. This is a Missouri form and can be use in Workers Comp.
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Tags: Self Insured Trust Safety Program Initial Certification Procedures, WC-129, Missouri Workers Comp,
COURT
COUNTY .OF. . . . DEPARTMENT. OF .LABOR .AND .INDUSTRIAL.RELATIONS
. . . . . . . .MISSOURI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. ..
DIVISION OF WORKERS COMPENSATION
:
Index No.
WORKERS SAFETY PROGRAM
:
SELF-INSURED TRUST Calendar No.
SAFETY PROGRAM
:
INITIAL CERTIFICATION PROCEDURES
JUDICIAL SUBPOENA
Plaintiff(s)
-against-
:
The following represents a general outline of the procedures to :be followed in certifying the safety programs
of self-insured trusts. These procedures will be the same for trusts utilizing third party administrators
(TPAs) and for self-administered trusts. The certification criteria for trusts generally follows the guidelines
:
used for insurance carrier certification as outlined in 8 CSR 50-7.040.
Defendant(s)
:
......................................................
1. Meeting with trust administrators or the person responsible for the delivery of occupational safety and
health services to trust members.
THE PEOPLE OF THE STATE OF NEW YORK
2. Review of written safety and health programs used to service the trusts loss control needs.
TO
3. Review of the educational materials available to trust members.
4. Review of credentials of loss control personnel.
GREETINGS:
5. Review of loss history of the trust members, including occupational injury and illness incidence rates,
WE COMMAND YOU, that all business and excuses being laid
loss run information and current experience modification factor. aside, you and each of you attend before
,
the Honorable
at the
Court
County of of loss control auditslocated at with individual trust members.
6. Review
performed
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
7. Identification of trust members with which to have on-site inspections. Inspections are performed for
the purpose of determining the adequacy and appropriateness of the services and programs provided. A
minimum of two on-site inspections will be performed for each trust.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf thisand reports with recommendations are sent of $50 Self-Insurance Unit. Trusts a
8. On-site inspection audits subpoena was issued for a maximum penalty to the and all damages sustained as
result of your failure to comply.
that meet the guidelines will receive certification. Trusts that are unable to be certified will be given six
months to comply with the recommendations. If recommendations are not satisfactorily acted upon in
Witness, Honorable
, one of the Justices of the
six months, the trust will be denied certification and referred to the Self-Insurance Unit for further
Court in
County,
day of
, 20
action.
9. The Workers Safety Program will annually perform a review of each trusts safety program after the
(Attorney
initial certification. The review will cover any changes made to must sign above and type name below) include
the certified program and may
on-site visits.
Attorney(s) for
10. Written allegation of safety violations may result in additional reviews.
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
WC-129 (03-01) AI
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