Utah > Workers Compensation
Home Builders Association Questionaire 1022 - Utah
| Home Builders Association Questionaire Form. This is a Utah form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
HOME BUILDERS ASSOCIATION QUESTIONNAIRE INSTRUCTIONS 1. Complete all sections. 2. If you have questions while completing the questionnaire, call 801-288-8020 or 800-446-2667 ext. 8020. 3. Return the completed questionnaire to WCF either by fax or mail. Fax# 801-288-8554 Workers Compensation Fund Attn: Underwriting Department 392 East 6400 South COMPANY DATE COMPANY CONTACT PERSON TITLE POLICY NUMBER WCF AGENT OR MARKETING REP 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 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | YES NO EXCEPTIONAL Do you have a formal machinery and equipment maintenance program? MEDICAL FACILITIES Do you utilize WCF preferred provider medical facilities? YES NO If no, are you willing to? YES NO If yes, list providers/facilities: ____________________________________________________________________________________ EMPLOYEE HIRING/RETENTION Number of current employees: ______________ Check all you require as part of hiring: 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. Number of W2s last year: ___________ Post-offer physical Other: ______________ Short-term disability Sick leave __________________________________________________ Drug testing References verification Training/orientation Dental Life insurance FMLA Vision Wellness/fitness program Other: Conduct drug testing at random. Employee handbook includes disciplinary policy for rule violations. Union shop. SAFETY Do you have a written safety program in place? Year established: ___________ Describe directors safety experience: YES NO Name of safety director: ________________________________ ____________________________________________________________________________ ______________________________________________________________________________________________________________ Copyright © 2005 Workers Compensation Fund · HBA # WCF1022(9/05) American LegalNet, Inc. www.FormsWorkflow.com HBA QUESTIONNAIRE SAFETY (CONTINUED) Check all elements included in your safety program: Hazard communication Fall Protection Safety committee Incentives/contests Lockout/tagout Electrical Safety Hearing conservation Excavation Safety meetings Equiptment Operation PAGE 2 Describe responsibilities: __________________________________________________________ Describe: ________________________________________________________________________ Required and enforced Accident investigations Title of investigator(s): ____________________________________________________________ Personal protective equipment List equipment: ______________________________________________________________________________________ Supervisors are accountable for safety in their areas/departments. Other: ________________________________________________________________________________________________ Describe any recent changes, additions or modifications to your safety program: __________________________________________ ______________________________________________________________________________________________________________ Have you had any OSHA Violations in the past 5 years? YES NO If yes, list violations: ____________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Do you have a Early Return to Work program esablished? If yes, year established: ___________ 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: 1. Source: ______________________________________________________________________________________________________ Preventive measure(s): __________________________________________________________________________________________ ______________________________________________________________________________________________________________ 2. Source: ______________________________________________________________________________________________________ Preventive measure(s): __________________________________________________________________________________________ ______________________________________________________________________________________________________________ 3. Source: ______________________________________________________________________________________________________ Preventive measure(s): __________________________________________________________________________________________ ______________________________________________________________________________________________________________ MISC. List any significant changes planned for the next year: ________________________________________________________________ ______________________________________________________________________________________________________________ Any additional comments you consider important to this questionnaire: ________________________________________________ ______________________________________________________________________________________________________________ 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 ormedical 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
|
|||||||
