Accident Prevention Services Annual Report {DWC-109}

DWC109 Texas Department of Insurance Division of Workers' Compensation Workplace Safety · MS-27 7551 Metro Center Drive, Suite 100 Austin, TX 78744-1645 (512) 804-4626 phone · (512) 804-4619 fax Submit by email to: aps@tdi.texas.gov Accident Prevention Services Annual Report For Calendar Year Initial Report Subsequent Report I. INSURANCE COMPANY INFORMATION 1. Insurance Company Name 3. Group Name (if applicable) 4. Primary Texas Loss Control Contact Name 6. Contact Mailing Address (Street or PO Box, City, State, Zip Code) 8. A.M. Best Rating 5. Contact Phone Number 7. Contact E-mail Address 2. NAIC Number 9. Total number of workers' compensation policies in effect as of December 31st of the report year. II. ACCIDENT PREVENTION SERVICES INFORMATION 10. Provide the number of policies in the following premium groups that received any type of workers' compensation accident prevention services. a. Less than $25,000 b. $25,000-$100,000 c. More than $100,000 11. Total dollar amount the insurance company spent for accident prevention services for Texas workers' compensation policyholders: 12. Provide the following information regarding policyholder requests for accident prevention services. a. Total number of requests b. Number fulfilled 13. Number of workers' compensation accident prevention surveys performed: 14. Provide evidence of effectiveness and accomplishments of the insurance company's accident prevention services. 15. Total number of work-related fatalities incurred by policyholders during the calendar year: Boxes 16-26 Initial Report: Complete each box. Subsequent Report: For each box, check No Change or complete to indicate any change since last report. 16. Describe changes in ownership, organizational structure, or management of the insurance company since the last annual report that affect the provision of accident prevention services. No change 17. Describe the manner in which the insurance company determines a loss ratio. No change DWC109 Rev. 10/13 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 6 DWC109 18. Describe the following regarding the insurance company's accident prevention SURVEYS. a. Criteria the insurance company uses to evaluate and determine a policyholder's need for surveys No change b. Time frame and manner the insurance company follows to evaluate and determine a policyholder's need for surveys No change c. Time frame and manner in which the insurance company offers to provide surveys to policyholders No change d. Time frame and manner in which the insurance company provides surveys to policyholders No change e. Specify each entity that will provide the surveys No change Insurance carrier Contracted provider Contracted policyholder f. Method the insurance company uses to document provision of surveys to policyholder No change 19. Describe the following regarding the insurance company's accident prevention RECOMMENDATIONS. a. Criteria the insurance company uses to evaluate and determine a policyholder's need for recommendations No change b. Time frame and manner the insurance company follows to evaluate and determine a policyholder's need for recommendations No change c. Time frame and manner in which the insurance company offers to provide recommendations to policyholders No change d. Time frame and manner in which the insurance company provides recommendations to policyholders No change e. Specify each entity that will provide the recommendations No change Insurance carrier Contracted provider Contracted policyholder f. Method the insurance company uses to document provision of recommendations to policyholders No change DWC109 Rev. 10/13 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 6 DWC109 20. Describe the following regarding the insurance company's accident prevention TRAINING. a. Criteria the insurance company uses to evaluate and determine a policyholder's need for training No change b. Time frame and manner the insurance company follows to evaluate and determine a policyholder's need for training No change c. Time frame and manner in which the insurance company offers to provide training to policyholders No change d. Time frame and manner in which the insurance company provides training to policyholders No change e. Specify each entity that will provide the training No change Insurance carrier Contracted provider Contracted policyholder f. Method the insurance company uses to document provision of training to policyholders No change 21. Describe the following regarding the insurance company's accident prevention CONSULTATIONS. a. Criteria the insurance company uses to evaluate and determine a policyholder's need for consultations No change b. Time frame and manner the insurance company follows to evaluate and determine a policyholder's need for consultations No change c. Time frame and manner in which the insurance company offers to provide consultations to policyholders No change d. Time frame and manner in which the insurance company provides consultations to policyholders No change e. Specify each entity that will provide the consultations No change Insurance carrier Contracted provider Contracted policyholder f. Method the insurance company uses to document provision of consultations to policyholders No change DWC109 Rev. 10/13 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 6 DWC109 22. Describe the following regarding the insurance company's ANALYSIS OF ACCIDENT CAUSES. a. Criteria the insurance company uses to evaluate and determine a policyholder's need for analysis of accident causes No change b. Time frame and manner the insurance company follows to evaluate and determine a policyholder's need for analysis of accident causes No change c. Time frame and manner in which the insurance company offers to provide analysis of accident causes to policyholders No change d. Time frame and manner in which the insurance company provides analysis of accident causes to policyholders No change e. Specify each entity that will provide the analysis of accident causes No change Insurance carrier Contracted provider Contracted policyholder f. Method the insurance company uses to document provision of analysis of accident causes to policyholders No change 23. Describe the following regarding the insurance company's INDUSTRIAL HYGIENE SERVICES. a. Criteria the insurance company uses to evaluate and determine a policyholder's need for industrial hygiene services No change b. Time frame and manner the insurance company follows t