Accident Prevention Services Annual Report
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1
2Form HS-31-C
ARKANSAS WORKERS’ COMPENSATION COMMISSION
HS-
Ark. Code Ann. §11-
HEALTH & SAFETY DIVISION
9-409 & AWCC
324 Spring Street, Little Rock, AR 72201
31-C
Rule 31
Mail: P. O. Box 950, Little Rock, AR 72203-0950
Rev. 7-1-2010
501-682-3930 / 1-800-622-4472
A
P
S
A
R
CCIDENT
REVENTION
ERVICES
NNUAL
EPORT
1) Insurance Company:
3) Mailing Address:
4) City, State, Zip:
2) Telephone no.: (
)
5a) NAIC Company no.: ____________________
5b) NAIC Group no.:
____________________
6) Total amount spent for accident prevention services during the current calendar year (salaries, travel): $___________________
7a) Total amount of workers’ compensation insurance written manual premium in AR for year: $________________________
7b) Total amount of workers’ compensation insurance direct premium written in AR for year: $__________________________
7c) Premium information provided by: Name:
_____________________________
Office:
_______________________________
Employee
Contract
8a) Number of Field Safety Representatives (FSRs) used by the insurance company:
8b) Number of Approved Professional Safety Sources (APSSs) used by the insurance company:
9) Number of on-site inspections performed by FSRs:
10) Identify the number of AR workers’ compensation insurance policyholders for the most recent calendar year for the premium
groups listed:
_____
$0 - $24,999
_____ $25,000 - $49,999 _____ $50,000 - $74,999 _____ $75,000 - $100,000 _____
Above $100,000
Evidence of accident prevention effectiveness will be measured by an
11a) Current Year
11b) Previous Year (yyyy)
analysis of the following loss data:
(yyyy)
11c) Total number of medical-only workers’ compensation claims
opened:
11d) Total amount paid on medical-only claims:
11e) Total number of indemnity claims opened:
11f) Total amount paid on indemnity claims:
I certify that the above information is correct to the best of my knowledge and I have read and understand the provisions set by
Arkansas Code Ann. §11-9-409.
_______________________________________________
________________________________
______________________
Designated Insurance Company Representative (Print Name)
Position or Title
Date
_________________________________________________
Email Address
____________________________
Designated Insurance Company Representative (Signature)
HS-31-C
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