Provide a copy of each of the following,
if applicable, for each Client selected for verification.
- Risk Selection Documents
- Request for Proposal (RFP) or equivalent information
- Basic Client information (name, address, mailing
address, telephone number, etc) used to make decision
to accept Client’s risk (from WC perspective).
- Names, addresses etc, and FEIN numbers of all subsidiary
- All states in which prospect has employees.
- Description of prospect’s operation and all
- Recap of number of employees by WC code, by state, by job/position
description, and their associated WC wages for all subsidiary companies.
- Location address of any worksites with a concentration of 100 or more employees.
- Sign-off by Risk Manager (RM) that information
has been reviewed and determination made as to need
for worksite survey. If no worksite survey was required,
provide brief explanation.
- Tax Receipts or payroll documents obtained to verify wage information.
- WC Policy Declaration Page
Declaration page from prospect’s current WC policy
obtained prior to proposal. If not available, provide
- “Desktop” or Worksite Inspections
“Desktop” inspection report or notes completed by the risk manager
or responsible person.
If a worksite inspection was conducted, provide report and any loss requirements
generated by the inspection.
- Claims Reviews
WC claims data on which risk selection decision
was based and documentation of the analysis of the
claims information by the risk manager or other responsible
person. If no loss information was available for
the assessment process, provide explanation.
- Financial Risk Assessment Information
Include all information used to assess prospective
client’s financial stability and identify who
analyzed the information and made the decision on
the prospective clients’ acceptability from
a financial perspective.
- Referrals to the Carrier
Where referrals are required, provide documentation
that the prospective client was referred to the appropriate
carrier and confirm that carrier’s approval
was obtained prior to contracting with the prospect.
- Final Approval/Declination
Documentation noting who made the final decision
to accept or decline prospect and the date the decision
- Notice to Carrier of Client Addition/Deletion
Documentation of notification to the carrier of new client’s
addition. If this notification is by a means other
than faxes, e-mails or similar documents, provide an
explanation and an example.
- Client Service Agreement
Provide copy of current Service Agreement used with each
of the sample clients.
- Loss Prevention “Needs Assessments” and
- Provide documentation, regardless of format, describing
determination of the client’s service needs and
the planned services to address those needs. Service
needs may be determined during the risk assessment
phase or after the prospect has become a client. Note:
this should include your company’s standard operating
procedure for providing certain services, regardless
of any specific needs having been identified.
- On small, low-hazard risks, plan may only require
a one-time site visit. If no service required, there
should be an explanatory note in file.
- On larger, more complex risks, it is expected that
loss-prevention service will focus on the identified
loss sources and on assisting the client with implementing
required controls. Providing a customized Employee
Safety and Health Plan (Safety Manual) would be one
example of a service objective.
- Loss Prevention Service Documentation
- Provide internal memos or equivalent documentation
in any format, that provides a record of what was accomplished
during each service visit. Unplanned visits can be
conducted for a number of reasons, such as conducting
accident investigations or responding to special requests
by the client for assistance. These visits should be
documented in similar manner.
- Submit copies of documentation for the services provided
for the past 12 months. (Note: if no service was planned
and none delivered, it is understood there will be
no service documentation.)
- Employee Handbook
Provide a copy of the page or pages from the employee handbook,
which includes the client’s name and your name, and
explains the co-employment relationship. If you do not
provide handbooks or otherwise cannot submit this information,
please provide an explanation.
- Managed Care
Provide a copy of the worksite posting notice identifying
the selected medical provider for each sample client.
If this notice cannot be furnished, please provide