Texas > Workers Compensation > Health And Safety
Accident Prevention Services Worksheet DWC-105 - Texas
| Accident Prevention Services Worksheet Form. This is a Texas form and can be used in Health And Safety Workers Compensation . |
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TEXAS DEPARTMENT OF INSURANCE DIVISION OF WORKERS' COMPENSATION Workers' Health and Safety, MS-27 7551 Metro Center Dr. # 100 Austin, Texas 78744 PRE-INSPECTION EXCHANGE OF INFORMATION FOR ACCIDENT PREVENTION SERVICES EVALUATION SINCE LAST INSPECTION ON ________________ ACCIDENT PREVENTION SERVICES WORKSHEET 1a. Name / dba 1b. # of Employees 2b. Best Hazard Index 3c. Contact Person E-mail Address I. ACCOUNT INFORMATION 2a. Principal Texas office address 3b. Contact Person Phone Number 3a. Policyholder Contact Person 4a. Insurance Carrier 4b. Effective Date 4c. Date Form Completed 4d. Completed By II. SERVICE & LOSS INFORMATION 5a. CURRENT POLICY YEAR / / to / / 5b. FIRST PRIOR YEAR / / to / / 5c. SECOND PRIOR YEAR / / to / / 6. Premium 7. Number of Claims and Fatalities ( ) 8. Loss Ratio (%) 9. Date Loss Ratio Exceeded 100% and/or 250% 10. On-Site Visits (List All Dates) 11. Other Appropriate Services (List All Dates) 12. Description of operations. 13. List accident trends for current year and preceding 2 years. 14. Actual and/or potential loss sources? a. Specifically identified? Controlled? Describe controls. b. Recommendations submitted for control? Describe recommendations, follow-up and completion. 15. Safety Training needed/provided? 16. Loss Analysis needed/provided? 17. Industrial Hygiene/Health Service needed/provided? 18. Comments - Refer to other side of form for instructions; additional sheets may be used if necessary. DWC FORM-105 (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS FOR COMPLETING ACCIDENT PREVENTION SERVICES WORKSHEET (DWC FORM-105) 1a. 1b. 2a. 2b. 3a. 3b. 3c. 4a. 4b. 4c. 4d. 5a-c. 6. Name of policyholder and "dba" if applicable - (e.g., "South Padre Ocean Ride Transit, Inc." - dba "SPORT, Inc."). Number of covered Texas employees on latest policy renewal date. Policyholder's principal Texas office address. Hazard index according to A.M. Best Company. Policyholder contact person for Texas locations. Phone number of Texas contact person. E-mail address of Texas contact person. Name of insurance company. If the insurance company is a subsidiary company, enter subsidiary company. Date of annual renewal. If account is a new policy, include policy's inception date. Date worksheet was completed. Name of person who completed the worksheet. Dates for each policy year, (e.g., 10/01/96 to 9/30/97). Premium, as computed using the rate filed with the Texas Department of Insurance, prior to applying any adjustments or discounts, for each policy year. Number of claims in the current policy year to date and in each of the two prior policy years. Identify all fatalities by placing the number of fatalities in parenthesis next to the number of claims for that policy year. Loss ratio is the result of dividing the accumulated claims (including reserves) in a policy year by the premium determined when the policy is written, prior to applying any adjustments or discounts. State as a percentage. Indicate date(s) when loss ratio exceeded 100% for all accounts regardless of premium size. List date(s) when loss ratio exceeded 250% for all accounts with a premium between $5000 and $24,999. List dates of on-site visits only to the account made by the field safety representative(s) in each policy year. List dates of services provided in lieu of on-site visits which required direct contact to the account by the field safety representative(s) in each policy year. [In addition to the written solicitation of comments from each policyholder as required in Workers' Compensation Rule 166.4 (c)(2)(E).] 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. Insured has 3 locations and 12 vehicles.") Give a brief description of the policyholder's accident experience. Include trend observations and types of injuries. List the actual and potential hazards associated with the policyholder's operations which have or may cause losses. Describe methods employed by the insured to control these hazards. List recommendations made by the field safety representative(s) to control hazards. Include whether the management has implemented the recommendations, and what follow-up has been accomplished. Describe any safety training provided to the policyholders and any promotional or course materials provided for their safety training program. List training programs recommended by the field safety representative(s). Was a loss analysis provided to the policyholder to identify trends and the need for additional service? Did the policyholder's operations require industrial hygiene/health service? If yes, describe what services were provided by the insurance carrier. Comment on response or receptiveness of policyholder to recommendation(s) by field safety representative(s). Also note cancellation date of policy if no longer insured. 7. 8. 9. 10. 11. 12. 13. 14a. 14b. 15. 16. 17. 18. DWC FORM-105 (Rev. 10/05) Page 2 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com
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