Information Required for Verification of
Best Practices Compliance for Selected Client Files

(Program Manual Table 2)

Click here to access this Table 2 in a checklist format. You may:
1. View/print this file, or
2. Complete the form fields in the file and upload your saved version with each client's file materials.

Provide a copy of each of the following, if applicable, for each Client selected for verification.

  1. Risk Selection Documents
    1. Request for Proposal (RFP) or equivalent information containing:
      1. Basic Client information (name, address, mailing address, telephone number, etc) used to make decision to accept Client’s risk (from WC perspective).
      2. Names, addresses etc, and FEIN numbers of all subsidiary companies.
      3. All states in which prospect has employees.
      4. Description of prospect’s operation and all subsidiary companies.
      5. Recap of number of employees by WC code, by state, by job/position description, and their associated WC wages for all subsidiary companies.
      6. Location address of any worksites with a concentration of 100 or more employees.
      7. 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.
      8. Tax Receipts or payroll documents obtained to verify wage information.
    2. WC Policy Declaration Page
      Declaration page from prospect’s current WC policy obtained prior to proposal. If not available, provide explanation
    3. “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.
    4. 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.
    5. 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.
    6. 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.
    7. Final Approval/Declination
      Documentation noting who made the final decision to accept or decline prospect and the date the decision was made.
    8. 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.

  2. Client Service Agreement
  3. Provide copy of current Service Agreement used with each of the sample clients.
  4. Loss Prevention “Needs Assessments” and Service Plans
    1. 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.
    2. 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.
    3. 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.

  5. Loss Prevention Service Documentation
    1. 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.
    2. 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.)

  6. Employee Handbook
  7. 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.
  8. 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 an explanation.

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