Fillable One Year Request for Certification (Colorado DORA)

Fill Online, Printable, Fillable, Blank One Year Request for Certification (Colorado DORA) Form

Use Fill to complete blank online COLORADO DORA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

One Year Request for Certification (Colorado DORA)

On average this form takes 8 minutes to complete

The One Year Request for Certification (Colorado DORA) form is 4 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your DORA forms online.

Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

BROWSE COLORADO DORA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
Instructions for Completing the
One Year Request for Certification
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not
be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “Employer Name” box (field),
complete the information, and use the tab key to navigate to the next
field. Do not use the Enter
key; pressing the Enter key will only page
down. Each field has been limited. This means that you cannot
continue to type information into a field if it doesn’t fit into the space
provided.
Use numbers only
to fill in the fields for phone number, fax number and
dollar amounts. Do not use parentheses or dollar signs; when you tab
out of the field, it will fill in automatically.
To clear or delete all the information you have typed onto the form,
click on the red “Clear Entire Form” button. To clear all the informa-
tion on a single page, click on the red “Clear This Page” button To
change the information in one field, use the backspace or delete key.
Go to Form
2
“Clear Entire Form” button
Clears all information at once
“Clear This Page” button
Clears all information on this page
WC109 Rev 05/05 Page 1 of 3
DIVISION OF WORKERS’ COMPENSATION
Premium Cost Containment Program
REQUEST FOR CERTIFICATION
Employer Name: ____________________________________________________________
Employer FEIN: ____________________________________________________________
Employer Mailing Address: ____________________________________________________________
Employer City, State, ZIP: ____________________________________________________________
Name of Insurance Carrier: ____________________________________________________________
Policy Number: ____________________________________________________________
Nature of Business: ____________________________________________________________
Date Program Was Implemented: ____________________________________________________________
To obtain certification status in the Colorado Workers’ Compensation Premium Cost Containment Program, it
must be demonstrated that the applicant employer has actively followed an approved loss prevention and loss
control program for a period of at least one year. Copies of loss prevention documentation clearly showing
compliance with each of the following requirements has been in effect for at least one year, must accompany this
Request for Certification.
THE APPLICANT EMPLOYER MUST PROVIDE THE DIVISION WITH DOCUMENTATION OF
THE FOLLOWING COST CONTAINMENT PROGRAM REQUIREMENTS
1. Formal Declaration of an Organization-wide Loss Prevention and Loss Control Policy (enclose a signed and
dated copy).
a. The policy reflects the philosophy of top management.
b. The safety and health of all employees are a top priority.
2. Formal Creation of a Safety Committee or Coordinator (enclose signed and dated documentation).
a. Committee or coordinator has clearly defined tasks and objectives.
b. Discuss/recommend safety policies and objectives.
c. Identify unsafe conditions and practices.
d. Investigate all accidents.
e. Conduct safety committee meetings and promote safety awareness.
f. Establish and update safety rules.
3. Clearly Defined and Conspicuously Posted Safety/Loss Prevention Rules (enclose a signed and dated copy).
a. Hazards are identified and accident prevention rules are clearly communicated.
b. All employees are made aware of the safety rules.
c. Safety rules are applicable and updated as needed.
4. All Employees Undergo Safety Awareness and Loss Prevention Training (enclose signed and dated
verification of employee safety training).
a. The supervisor has provided and documented individual job/task safety training.
b. Ongoing safety meetings are held for all employees and attendance (employee sign-off) recorded.
5. Written Designation of a Medical Provider (enclose a signed and dated copy).
a. Provider is knowledgeable of fee schedules and agrees to honor designated provider agreements.
b. Provider communicates with the employer on issues such as case management and modified duty.
c. Employer will keep in contact with the injured worker and will inform employees on matters
concerning the designated medical provider.
Clear This Page
Clear Entire Form
Back to Instructions
WC109 Rev 05/05 Page 2 of 3
6. Written Policies and Procedures on Claims Management (enclose a signed and dated copy).
a. Employer has investigated all incidents for third-party potential (enclose a completed investigation).
b. Employer ensures that the insurance carrier is contacted in a timely manner and confirms that the
employee was working at the time of the accident.
c. Employer coordinates with the insurance carrier (at least annually) on issues such as loss runs review,
outstanding reserves, and employee classification.
d. Employer, when practicable, institutes a modified duty program in conformance with the attending
physician’s restrictions (enclose modified duty documentation).
7. Use the following chart to provide a summary for EACH of the last three full policy periods, and the current
policy year-to-date of your organization’s injuries, costs, and total employee hours worked. This
information MUST be provided by POLICY period. Information should be taken from insurance carrier
loss reports and payroll records. Read the attached instructions before completing
.
Policy Period
Effective Date
Expiration Date
No. Of Injuries
During Policy
Period
Total Costs Incurred on All
Claims During Policy Period
Total Employee
Hours Worked
During Policy Period
8. A currently valued copy (valued no more than 30 days prior to the date of application) of your insurance
carrier’s detailed, gross loss reports for the last three full policy years, and the current policy year-to-date
MUST be included with this request for certification. Read the attached instructions for further information
.
NOTE: An on-site evaluation of the employer’s Cost Containment Program may be conducted
.
By signing this request, the contact person affirms that the above requirements have been met and
acknowledges the Premium Cost Containment Program may contact the applicant employer’s workers’
compensation insurance carrier to obtain information relative to this request.
_________________________________________________
Signature of Contact Person
______________________________________
Date of Signature
_________________________________________________
Type or Print Name of Contact Person
______________________________________
E-mail Address
___________________________________________
Contact Person’s Telephone Number
_____________________________________
Fax Number
PLEASE RETURN THE COMPLETED FORM CONTAINING THE ORIGINAL SIGNATURE OF THE
CONTACT PERSON. ATTACH ALL REQUIRED DOCUMENTATION.
Premium Cost Containment Program Board
Division of Workers’ Compensation
633 17th St., Suite 400
Denver, CO 80202-2117
Clear This Page
WC109 Rev 05/05
Page 3 of 3
INSTRUCTIONS FOR COMPLETING ITEMS 7 & 8
Please read before completing Request for Certification form.
ITEM 7 - Summary Chart
1) Policy Period
is defined as the policy year or partial policy year reflected on loss reports. These periods
might not coincide with the calendar year. DO NOT convert policy periods to calendar years (i.e., If policy
period is shown on loss reports as July 1 - June 30, the policy period should be reported as shown).
2) Number of Injuries
is defined as the number of claims reported to your insurance carrier. In some
cases, this will include reports of injuries that have incurred no costs. (All injuries should be reported to your
carrier, regardless of severity). OSHA reporting requirements are not a consideration.
3) Total Costs on All Claims
is defined as the gross incurred amount, and includes both paid and
outstanding reserve amounts. This includes medical costs, indemnity costs, and miscellaneous expenses.
Deductible amounts paid by the insured employer must also be included in this figure.
4) Total Employee Hours Worked
is defined as the total number of hours worked by all employees
during each indicated policy period. There is no need to break this figure down into "regular" and "overtime"
hours, nor is it necessary to differentiate between "exempt" and "nonexempt" employee hours. Hours MUST
NOT be extended beyond the valuation date of loss reports (i.e., if loss reports are valued as of June 30, hours
worked should be reported only through June 30 even though the date of the application may be July 20).
ITEM 8 - Loss Reports
Currently Valued
loss reports from your insurance carrier covering the last three full policy periods and the
current policy year-to-date must accompany all requests for certification or recertification. In order to be
currently valued, ALL loss reports must have been printed within thirty days of the date of application.
Only actual detailed, gross valuation loss reports are acceptable. On-line printouts, summary loss reports and
loss reports that do not include deductible amounts are unacceptable for program purposes. Summaries
prepared by agents or brokers and in-house accounting program printouts are generally not acceptable.
Original signatures are required. Failure to properly complete this request form or provide the
required loss reports will delay the processing of your request.
If you have any questions, please contact the Premium Cost Containment Program
303.318.8644
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

One Year Request for Certification (Colorado DORA)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document