Workers Compensation Fund General Business Supplemental Questionnaire Please Print or Type 1 Policy Information Company Company Contact Person WCF Agent or Marketing Rep Title Policy Number Date 2 Physical Location Describe your business's operations ( i.e. products / services, processes, distribution, etc. ) List any operation changes during the past year Rate your housekeeping ( i.e. cleanliness / sanitation ) Poor | 1 | 2 | Yes 3 | No 4 | 5 | 6 | 7 | 8 | 9 | 10 | Exceptional Do you have a formal machinery and equipment maintenance program? 3 Medical Facilities Do you utilize WCF preferred provider medical facilities? Yes No If no, are you willing? Yes No 4 Employee Hiring / Retention Number of Current Employees Employment Application Post Accident Drug Testing Check Any Employment Benefits You Offer Medical Long-term disability Paid vacation Other Employment Standards Conduct drug testing for cause Employee handbook includes work / safety rules Union shop Conduct drug testing at random Employee handbook includes disciplinary policy for rule violations Dental Life insurance FMLA Vision Wellness / fitness program Other Short-term disability Sick leave References Verification Training / Orientation Number of W2s Last Year Post-Offer Physical Other Drug Testing 5 Safety Do you have a written safety program in place? Describe directors safety experience Yes No Year established Name of safety director Check all elements included in your safety program Hazard communication Fall protection Lockout/tagout Electrical safety Hearing Conservation Excavation Safety meetings Equipment Operation WCF 1022 (Rev. 6/11) American LegalNet, Inc. www.FormsWorkFlow.com 5 Safety (cont'd) Safety committee, describe responsibilities Incentives / contests, describe Accident investigations, title of investigator(s) Personal protective equipment, list equipment required and enforced Describe any recent changes, additions or modifications to your safety program Have you had any OSHA Violations in the past 5 years? If yes, list violations Yes No Do you have an early return to work program established? Yes No Year established Modified duty position? Yes No 6 Claims List your three largest sources of workers compensation claims (e.g., slips and falls, cuts, ergonomics, etc.) and any preventive measure(s) you have taken: Source A Preventive measure(s) Source B Preventive measure(s) Source C Preventive measure(s) 7 Miscellaneous List any significant changes planned for the next year Any additional comments you consider important to this questionnaire Print Name Signature Date For your protection, Utah law requires the following to appear on this form: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in the state prison. WCF 1022 (Rev. 6/11) American LegalNet, Inc. www.FormsWorkFlow.com