HOME HEALTH CARE WORKERS COMPENSATION APPLICATION Insured Information Named Insured & dba Mailing Address Physical Address FEIN Contact Information Contact Person Phone Email Primary Contact Risk Control/Safety Director Billing/Audits Principal/Owner Name Title Ownership % Duties Include/Exclude Remuneration President Vice President Treasurer Secretary General Information Year Operations Began Year Current Management Began License Number Date License Renews Type of Entity Corporation LLC Non profit For profit Other: Operations Skilled Home Healthcare Services Hospice Non Skilled Personal Care or Assistance with Daily Living Other: Association Memberships AHHC of NC Other: Policy Information Renewal Date Experience Modification for proposed policy year: Employers Liability Limits (Current) $100,000/$500,000/$100,000 $500,000/$500,000/$500,000 $1,000,000/$1,000,000/$1,000,000 Other: Anniversary Rating Date (if different from Renewal Date) Employers Liability Limits (Options Requested) $100,000/$500,000/$100,000 $500,000/$500,000/$500,000 $1,000,000/$1,000,000/$1,000,000 Other: Summary of Insurance Company and Loss History Loss Runs Policy Period Insurance Company Attached? # Claims Total Payroll / /10 11 / /09 10 / /08 09 / /07 08 / /06 07 / /05 06 Experience Modification Factor Total Losses Premium Page 1 of 7
Classification of Employees Payroll Classification Description State Class Code Approximate # of Employees (FT/PT) Annual Payroll Clerical 8810 / Public Health Nursing 8835 / Outside Sales 8742 / Number of Volunteers Do volunteers receive any type of compensation for their services What are their duties? How many hours did volunteers work last year? Are volunteers subject to the same screening practices as employees? Are volunteers required to sign a waiver of liability in favor of the employer? Number of Students in Training Do students receive any type of compensation for their services? Does the insured provide any labor to staffing companies? Deductibles Are any deductibles currently utilized? What is the level of the deductible? Options to consider: $100 $250 $500 $1,000 $2,500 $5,000 $10,00 0 $25,000 Other $ Please comment where appropriate & include any attachments that provide a better understanding of your answer. Employees Hiring & Screening & Orientation Yes Nc Comment Are Job Descriptions provided? Y N Do they include physical requirements of each position? Y N Do you perform post offer physicals? Y N Do you perform pre employment physicals? Y N Do your pre placement physicals include ergonomic testing for lifting capabilities if the job requires it? Y N Are any of your employees a member of a union? Y N Are the following obtained and filed as part of your employee screening and hiring process? Y N Applications Y N Education and Competency Y N Licenses/Annual Confirmation Y N Question regarding latex allergies Y N Experience / References Y N Criminal Background Checks Y N National Sex Offenders check Y N Multi state Registry Y N TB Testing Y N Hepatitis Vaccinations Y N At orientation, are the work comp roles of employer, employee and carrier thoroughly explained? Y N Do you have a written employee safety program? Y N Number of hours allocated to employee safety education and training annually: Is training documented? Y N Are online education tools a part of your employee education/inservice programs? Y N If yes, what product do you use? If no, have you considered online education tools? Page 2 of 7 # of hours
Patient Handling / Lifting / Transfer Program Do you have a formal written Patient Lifting and Transfer Program? Y N Do you require the use of Gait Belts for all manual transfers? (unless contraindicated by a patient s medical condition) Y N Do you utilize mechanical lifting devices in the home whenever possible? Y N Do you provide formal education by a Licensed Physical Therapist for all direct care staff with return demonstration upon orientation and at least annually? Y N What percentage of clients are non ambulatory % Universal Precautions Are you aware of any cases of infectious diseases that might be attributable to an incident involving a blood borne pathogen (needle or sharps stick, bites, etc )? Y N Do you administer injections? If so, what controls are in place for this exposure? Y N Transitional Return To Work Program Do you have a Transitional Return to Work program for injured workers? "Light Duty / Early Return to Work program) Y N Do you have a specific person who maintains contact with the injured worker? Y N Do you have a specific person who maintains contact with the injured worker s physician? Y N Do you have any employees who are currently on light duty? (If yes, provide details) Y N Do you have written job descriptions for all jobs including those that might be used for light duty? Y N Do you have a Job Safety Analysis for each job? Y N Drug Testing Do you require drug testing? Y N Pre employment Y N For Cause Y N Post Accident Y N Random Y N Would you consider doing drug testing in the referenced areas if you are not doing it now? Y N Sub Contracting Exposure Do you provide a 1099 to any independent contractors who work for you? Y N Describe: Do you require a certificate of insurance for Workers Compensation for these contractors? Y N What services do you subcontract out? Do you collect certificates of insurance for Workers Compensation from these contractors? Y N Site Assessments Are home assessments conducted prior to employees beginning work in the home? Y N Page 3 of 7
Transportation/Driver Safety How many employees are responsible to drive company vehicles on a regular basis? What is the service radius of the individual in home aides? Are pre employment Motor Vehicle Reports (MVRs) reviewed? (or post offer?) Y N How often are they reviewed after employee has been hired? Y N How many employees utilize their personal vehicles for business purposes? Are employees allowed to drive client s vehicles? Y N Any drivers under age 25? (Provide number and details) Y N Do employees transport clients to appointments or on errands? Y N Are defensive driving courses or other training courses offered or required? Y N Are seatbelts mandatory for all passengers and drivers? Y N # of employees miles # of employees Physician Partnership Do you have a partnership with a local medical group to provide care for employees injured on the job? (List name of medical group) Y N Is the medical provider familiar with your place of employment? Y N Do you have a panel of physician s posted that employees use for workplace injuries? Y N Do you provide your Medical Provider with sample return to work job descriptions? Y N Are injured employees given specific instructions regarding approved providers and return to work procedures at the time of injury? Y N Do you provide your Medical Provider with a physical evaluation form including specific task limitations and / or restrictions if applicable? Y N Post Injury / Claim Management Are workplace accidents reported to your insurance company within 24 hours? (If not, what is your policy and what is the average reporting time?) Y N Do you have a specific person responsible for reporting accidents to your insurance carrier? (Provide name) Y N For multi location organizations, are claims field and managed by a corporate level employee or do individuals at the agency level file claims? Y N Do you treat any worker injuries on site? Y N Are all injuries reported to your insurer? Y N Are you compliant with OSHA reporting? Y N Do you maintain the OSHA 300 Log? Y N Do you have an injured employee accident kit that is taken to the physician during the first and all subsequent visits? (An accident kit includes your returnto work statement, job duty restriction analysis, etc ) Y N After a claim occurs, is a brief summary of the benefits available explained to the employee and is return to work discussed? Y N Are you active in the management of claims after you turn in the incident to your insurance carrier? Y N Do you routinely receive claim reviews from your insurance company? Please note frequency and comment on whether this meets your expectations. Y N Internally, who is responsible for the follow up with the injured employee until the claim is closed? Do you use any type of claims checklist to insure all your post accident strategies are used on all claims? Y N Page 4 of 7
Safety Committee/Monitoring Incidents/Accidents Do you have a designated safety committee? (If yes, then answer the following) Y N Do you have a designated Safety Chairman? (Give name) Y N List all positions represented on your safety committee(s) (i.e. HR, CFO, Nurses Aid, etc ) Are employees actively involved in safety practices? Y N Are written reports prepared? Y N Are corrective actions taken? Y N Is there a follow up procedure in place? Y N Do you currently have a system to monitor your incidents or accidents? Y N If yes, do you utilize software to help in this area? Y N How often are open claims reviewed at the Executive Committee level and what actions are taken after that input? What services or products would you like that are not currently being provided? Benefits: Indicate which of the following employee benefits are currently in place: Health Insurance (Participation Rate: %) Vision Life Other: Dental 401 (k) / 403 (b) Other: Other: Please attach the following: 5 years of currently dated loss history Provide details for each claim in excess of $25,000 Most recent Experience Modification Worksheet or a signed Experience Modification Request Letter on your letterhead (Attached) Application Completed by: Position: Date: Signature: Provide Completed Application to: BB&T Insurance Services, Inc. Healthcare Services Group PO Box 31128, Raleigh, NC 27622 1128 servicenow@bbandt.com Phone: 866.249.0293 Fax: 866.925.7116 CONFIDENTIAL Page 5 of 7
Use this form if 100% of your operations are within North Carolina Place letter on Company Letterhead (Complete this form only if you do not have your current Experience Modification Worksheet), 2010 North Carolina Rate Bureau 5401 Six Forks Road PO Box 176010 Raleigh, NC 27609 Dear Customer Service Representative: Please provide my Experience Rating Worksheet to the individual below: BB&T Insurance Service Inc Health Services Group PO Box 31128 Raleigh, NC 27622 1128 Phone: 866.249.0293 Fax: 866.925.7116 Email: servicenow@bbandt.com Thank you. Sincerely, Name: Title: Page 6 of 7
Use this form if any of your operations are outside of North Carolina Place letter on Company Letterhead (Complete this form only if you do not have your current Experience Modification Worksheet), 2010 NCCI Atlantic Division 750 Park of Commerce Drive Boca Raton, FL 33487 9951 Dear Customer Service Representative: Please provide my Experience Rating Worksheet to the individual below: BB&T Insurance Service Inc Health Services Group PO Box 31128 Raleigh, NC 27622 1128 Phone: 866.249.0293 Fax: 866.925.7116 Email: servicenow@bbandt.com Thank you. Sincerely, Name: Title: Page 7 of 7