Voluntary Drug-Free Workplace Programs VDFWP Annual Insurance Carrier Report {HS-36-B}

ARKANSAS WORKERS' COMPENSATION COMMISSION Form HS-36-B HEALTH & SAFETY DIVISION Ark. Code Ann. §11-14-101 & AWCC Rule 36 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 HS36-B Voluntary Drug-Free Workplace Program (VDFWP) Annual Insurance Carrier Report Carrier Information 1) Insurance Carrier: 2) Address: 3) City: 4) State: 5) Zip: 6) NA IC Ca rrier Identific ation No .: 8) Con tact: 9) Telephone: ( ) 7) NA IC Insu rance G roup N o.: 10) e-M ail: Client Information Please complete the following information for each client awarded premium credits for the most recent calendar year for its Voluntary Drug-Free Workplace Program (VDFWP) Client Name Address Did the insurance company audit the client's VDFWP Yes No Briefly note any assistance provided to the client by the insura nce com pany in either implementing or maintaining its VDFWP I certify that the above information is correct to, the best of my knowledge, and I have read and understand the provisions of Ark. Code Ann. §11-14-101 & AWCC Rule 36. __________________________________________________________ ____________________________ Designated Insurance Company Representative Position o r Title ________________ Date HS-36-B American LegalNet, Inc. www.FormsWorkFlow.com