Texas Department Of Insurance Division of Workers’ Compensation Workplace Safety 7551 Metro Center Dr. Ste.100 • MS-93 Austin, TX 78744-1609 (512) 804-4000 (512) 804-4001 fax www.tdi.state.tx.us ACCIDENT PREVENTION SERVICES WORKSHEET (DWC Form-105) 1. ACCOUNT INFORMATION 1a. Name/dba 1b. Number of Employees 2. Principal Texas Office Address 2a. Best Hazard Index Number 3a. Policyholder Contact Person 3b. Contact Person Phone Number 3c. Contact Person E-Mail Address 4a. Insurance Company 4b. Effective Date 4c. Date Form Completed 4d. Completed By 2. SERVICE & LOSS INFORMATION 5a. CURRENT POLICY YEAR / / to / / 5b FIRST PRIOR YEAR / / to / 5c SECOND PRIOR YEAR / / / to / / 6. Premium 7. Number of Claims 8. Number of Fatalities 9. Loss Ratio (%) 10. Date Loss Ratio Exceeded 100% and/or 250% 11. On-Site Visits (List All Dates) 12. Other Appropriate Services (List All Dates) 13. Loss Analyses (List All Dates) 14. Solicitation Letters (List All Dates) 15. Written Notification of Actual Claims (List All Dates) 16. Policyholder Evaluations (List All Dates) 17. Policyholder Requests (List All Dates) 18. Policy Declaration Page has required wording? YES NO PLEASE SEND A SAMPLE POLICY DECLARATION PAGE 19 Description of Operations: 20. Comments: NOTE: All files may be audited for accuracy and compliance with DWC rules. DWC105 Rev. 04/09 Division of Workers’ Compensation American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING ACCIDENT PREVENTION SERVICES WORKSHEET (DWC Form-105) 1a. Name of policyholder and "dba" if applicable; e.g., "South Padre Ocean Ride Transit, Inc." - dba "SPORT, Inc.". 1b. Number of covered Texas employees on latest policy renewal date. 2. Policyholder's principal Texas office address. 2a. Enter the Hazard Index no. for Workers’ Compensation according to A.M. Best Company. 3a. Policyholder contact person for Texas locations. 3b. Phone number of Texas contact person. 3c. E-mail address of Texas contact person. 4a. Name of insurance company. If the insurance company is a subsidiary company, enter subsidiary company. 4b. Date of annual renewal. If policyholder is new, insert policy's inception date. 4c. Date worksheet was completed. 4d. Name of person who completed the worksheet. 5a-c. Dates for each policy year; e.g., 10/01/2008 to 9/30/2009. 6. Premium, as computed using the rate filed with the Texas Department of Insurance, prior to applying any adjustments or discounts, for each policy year (Manual Premium). 7. Number of claims in the current policy year to date and in each of the two prior policy years. 8. Number of fatalities in the current policy year to date and in each of the two prior policy years. Explain under Comments below the type(s) of fatalities (vehicle, fall, heart attack) and reason(s) why policyholder was not visited during required 3 day time frame. 9. Loss ratio is the result of dividing the cost of accumulated claims (including reserves) in a policy year by the premium determined when the policy is written, prior to applying any adjustments or discounts (Manual Premium). State the loss ratio as a percentage. 10. For all policyholders, regardless of premium size, indicate date(s) when the loss ratio exceeded 100%. List date(s) when the loss ratio exceeded 250% for all policyholders with a premium between $5,000 and $24,999. 11. List dates of on-site visits to the policyholder in each policy year. 12. List dates of services provided in lieu of on-site visits (other appropriate services), which required direct contact with the policyholder by your insurance company’s loss control representative(s) in each policy year. This is in addition to the written solicitation for comments (#14) sent or given to each policyholder as required in DWC Rule 166.4 (c)(2)(E). 13. List all dates loss analyses were conducted at on-site visits and/or were sent to policyholder. 14. List all dates solicitation for comments letters were sent to policyholder. 15. List all dates notification of actual claims were given or sent to policyholder. 16. List all dates evaluations of the need for service of the policyholder were done. 17. List all dates the policyholder requested service from your insurance company’s loss control representative(s). 18. Check the policy declarations page and verify that the wording required by DWC Rule 166.4(c)(8)(B) is included. Please include a sample copy of the page with your worksheets. 19 Enter the policyholder's type of business. Include a description of the kinds of operations involved as well as their size; e.g., "Wire goods manufacturing. Bulk rolls of coiled wire and sheet metal are cut to size, welded and painted or plated. Policyholder has 3 locations in Texas in Dallas, Austin, and San Antonio.” 20. Comments should include any explanation of the above matrix answers, if needed. Also note cancellation date of policy if no longer insured. DWC105 Rev. 04/09 Division of Workers’ Compensation American LegalNet, Inc. www.FormsWorkflow.com