Workers Compensation Fund Home Builders Association Questionnaire Please Print or Type 1 POLICY INFORMATION Company Date Company Contact Person Title WCF Agent or Marketing Rep Policy Number 2 PHYSICAL LOCATION Describe your business's operations ( i.e. products / services, processes, distribution, etc. ) List any operation changes during the past year 2 EMPLOYEE LEASING OR STAFFING OPERATIONS (check all that apply) Own or Operate a Leasing or Staffing Company Lease Employees 3 MEDICAL MANAGEMENT Utilize WCF preferred Provider Network First Aid Kits Early Return to Work Program Employee First Aid/CPR Training 4 SAFETY DEVICES (CHECK ALL THAT APPLY) Personal protective equipment, list equipment: required and enforced Company Vehicles Motor Vehicle Records Checked Mandatory Seat Belt Policy WCF 1022 (Rev. 9/07) Pre-hire Quarterly Scheduled Maintenance Program Biannually Annually Defensive Driving Training Program American LegalNet, Inc. www.FormsWorkflow.com 5 EMPLOYEE SELECTION, TRAINING, SUPERVISION (check all that apply) Number of Current Employees Number of W2s Last Year Total Number of Shifts Number of Employees per Shift Employment Application Personal Interviews References Verification Drug / Alcohol Program Pre-hire Drug Testing Random Drug Testing For Cause Drug Testing Post Accident Drug Testing Medical Benefits Long-Term Disability Short-Term Disability Union Shop New Employee Safety Training Documented Safety Meetings Safety Incentives/Contests Discipline Program 6 EMPLOYEE SELECTION, TRAINING, SUPERVISION (check all that apply) Safety Director Name of Safety Director Fleet Director Name of Fleet Director Safety Committee Scaffold Safety Program Forklift Certification Program Hazard Communication Program Written Safety Program Blood-Borne Pathogens Program Confined Spaces Program Hearing Protection Program Lock Out/Tag Out Program Respiratory Protection Program Fall Protection Program Crane Safety Program OSHA 300 Log Accident Investigation 7 LOSS INFORMATION (please list most common injuries and preventive measure(s) you have taken in the space below.) Print Name Signature Date Please return a completed signed application to: Workers Compensation Fund Attn. Underwriting Department 392 East 6400 South Salt Lake City, Utah 84107 If you have any questions, please call 801.8020 or 800.446.2667 ext. 8020 Fax: 801.288.8554 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. 9/07) American LegalNet, Inc. www.FormsWorkflow.com