Accident Prevention Services Worksheet {DWC-105}

DWC105 Texas Department of Insurance Workplace Safety · MS-27 7551 Metro Center Drive, Suite 100 Austin, TX 78744-1645 (512) 804-4626 phone · (512) 804-4619 fax Division of Workers' Compensation Accident Prevention Services Worksheet I. POLICYHOLDER INFORMATION 1. Policyholder Name 3. Number of Employees 5. A.M. Best Hazard Index Number 2. Policy Number 4. Effective Date of Policy 6. Primary NAICS Code 7. Principal Texas* Office Address of Policyholder (Street or PO Box, City, State, Zip Code) * if no Texas office, use principal corporate address 8. Policyholder Contact Name 9. Contact Phone Number 10. Contact Email Address II. INSURANCE COMPANY INFORMATION 11. Insurance Company Name 12. Name of Person Completing the Form 13. Date Form Was Completed III. SERVICE AND LOSS INFORMATION 14. Provide Service and Loss Information for Policy Years as Requested by TDI-DWC Current 1st Prior 2nd Prior YEAR / / / / / / 3rd Prior / / a. Total Premium b. Number of Claims c. Number of Fatalities d. Date(s) of Fatalities e. Loss Ratio f. Experience Modifier g. Date(s) of Surveys DWC105 Rev. 10/13 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 DWC105 Provide Service and Loss Information for Policy Years as Requested by TDI-DWC (continued) Current 1st Prior 2nd Prior 3rd Prior YEAR / / / / / / / / h. Date(s) of Recommendation Letters i. Date(s) of Training Programs j. Date(s) of Consultations k. Date(s) of Analyses of Accident Causes l. Date(s) of Industrial Hygiene Services m. Date(s) of Industrial Health Services YEAR Current / / 1st Prior / / 2nd Prior / / 3rd Prior / / Date(s) of Request Date(s) Service Provided Date(s) of Request Date(s) Service Provided Date(s) of Request Date(s) Service Provided Date(s) of Request Date(s) Service Provided n. Policyholder Requests for Services o. Underwriting Requests Date(s) of Offer to Provide Service Date(s) of Offer to Provide Service Date(s) of Offer to Provide Service Date(s) of Offer to Provide Service Date(s) of Determination Date(s) of Determination Date(s) of Determination Date(s) of Determination p. Insurance Company 166.2(b)(3) Determinations DWC105 Rev. 10/13 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 DWC105 q. Description of Policyholder's Operations r. Comments NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). Frequently Asked Questions Accident Prevention Services Worksheet Who must file the DWC Form-105? Insurance companies undergoing inspections by the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) pursuant to 28 Texas Administrative Code §166.5 (Inspections of Adequacy of Accident Prevention Facilities and Services) must file the DWC Form-105. Insurance companies are responsible for timely and accurately filing the DWC Form105. A DWC Form-105 is considered filed with the TDI-DWC only when it accurately contains all of the required data elements. When do I file the DWC Form-105? After October 1, 2013, an insurance company must file a completed DWC Form-105 for each policy selected by the TDI-DWC at least 10 days prior to the scheduled date of the inspection. How do I file the DWC Form-105? The DWC Form-105 may be filed by mail or fax; the contact information is located on the top left hand side of the first page of this form. Or, the form may be emailed to the inspector responsible for the inspection as indicated on the TDI-DWC's request for information. Are any fields on the DWC Form-105 optional? No, all applicable fields must be completed each time the DWC Form-105 is filed. The number of policy years for which the information must be completed will be determined by the TDI-DWC and communicated to the insurance company during the pre-inspection exchange of information. DWC105 Rev. 10/13 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3