Contact Name: Phone Number: Best time to call:

Company Address City: State: Zip:

Workers Comp Info

Current carrier Present Experience Mod Last years Mod

This year's loss $$$ Last year's loss $$$ Year before last loss $$$

Current ARAP Date entered into the pool Current Agent

Questions

1. Do you have a formalize written safety program? (Yes     No )

2. Do you have a return to work program? (Yes    No )

3. Do you have a claims network setup? (Yes    No )

4. Is someone responsible for safety? (Yes    No ) and if yes, what percentage is this of their job?

5. Have you ever received a QLMP credit? (Yes    No ) If yes, when?

By submitting this document you understand that if what you represent is found to be misrepresentation, it can result in removal from the QLMP program, and this application does not guaranteed approval into the QLMP program.