INSTRUCTIONS FOR COMPLETING DWC-109 Item 1a: and 1b: 1c: List name; address of individual insurance company on which this report is being filed. Show parent group name (if applicable) and the NAIC number. Item 2: Total amount spent on services including: all accident prevention, travel, materials, salaries, contracted services, etc. Do not include underwriting visits to the policyholder's premises unless accident prevention services are provided during the visit. In that case, include the proportionate cost of the services rendered for workers' compensation (WC). Item 3: The total amount of workers' compensation premium must include only those policies with exposures in Texas and must be derived from the premium filed with Texas Department of Insurance before any adjustments or discounts are applied (experience modifiers, deductibles, retrospective amounts, or other adjustments). Include all policies with effective dates between January 1 and December 31. Item 4: The total number of workers’ compensation policies in effect at the time the report is filled out. Include all policies on company paper regardless of who produced the account. Item 5: Enter the A.M. Best Rating for the company at the time the report is filled out. Item 6: Indicate any change in ownership of the company or change in management of the Accident Prevention Services function. Item 7: Indicate only ON-SITE inspections performed for the workers' compensation coverage, and include the number of WC consultations performed. Do not include underwriting surveys on prospective accounts. Item 8: Include all contracted accident prevention services, even if only on a one-time basis. Item 9: Enter the number of policyholders that received accident prevention services in each indicated premium category. Use the definition of premium as indicated in Item 3, above. This should include all types of WC services, not just the on-site visits totaled in Item 6 above. Item 10a: Enter only the new claims opened during the Calendar Year (CY), not cases reopened. Include claims initially opened during the CY being reported even if the injury occurred in a prior year. 10b: Enter the total amount of money paid out on claims for the CY. 10c: Enter the total amount of reserve funds being held for all previous claims, regardless of CY, on December 31. This will be a "snapshot" look at reserves. 10d: Enter the total number of occupational fatalities incurred by all policyholders during the CY. *NOTE: Adjustments to the Previous CY column should only be made to reflect claims originally opened which did not materialize or which changed for some other significant reason. Please include a brief explanation for any changes from previously reported figures and attach it to this form. Form must include the authorized signature of the insurance company representative supplying the required information, telephone number, and date signed. The submission must be received by DWC by March 1 to be considered timely filed. Late submissions may be referred to the DWC Compliance and Practices Division to consider assessment of administrative violations and fines. DWC109 Rev. 12/05 TEXAS DEPARTMENT of INSURANCE/ DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.FormsWorkflow.com Texas Department of Insurance Division of Workers’ Compensation Workplace Safety, MS-27 7551 Metro Center Drive, Suite 100 Austin, Texas 78744-1609 512-804-4686 512-804-4619 fax www.tdi.state.tx.us Calendar Year (CY)______ ACCIDENT PREVENTION SERVICES ANNUAL REPORT 1. Insurance Company's Name 1b. Mailing Address (Street or P.O. Box, City, State, Zip) 1a. Group Name and NAIC # 2. Total amount spent for accident prevention services provided to Texas Workers' Compensation (WC) insureds: (Include WC proportional salaries, travel, materials, contracted services) $ ___________________ 3. Total amount of Texas workers' compensation insurance premium written: $ (See reverse for definition of premium) 4. Total number of workers’ compensation policies in effect at time of report. ________________ 5. What is the company’s A.M. Best rating? ____________ 6. Has there been any change in ownership or management of the company? 7. Number of workers' compensation "on-site" inspections performed: 8. Check the types of WC accident prevention services contracted outside the insurance company: Surveys Training Consultations Industrial Hygiene Industrial Health 9. Identify the number of accounts in the following groups that received any type of WC accident prevention services: $0-$4,999_______ $5,000-$24,999_______ $25,000 and above _____________ 10. Evidence of prevention effectiveness measured by an analysis of the following loss data: Recent CY Previous CY a. Total number of new WC claims opened in CY (not by injury date) b. Total amount paid on WC claims for each CY c. Total amount of WC reserves being held on December 31 d. Total number of occupational fatalities incurred by insureds in CY I certify that the above information is correct to the best of my knowledge. Authorized Signature for Insurance Company Typed/Printed Name DWC109 Rev. 12/05 ___________________________ Title or Position ____________ Date ( ) Telephone Number TEXAS DEPARTMENT of INSURANCE/ DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.FormsWorkflow.com