"Business Self Assessment Template - Workcomp Partners"

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WorkComp Self Assessment
________________________________________
To more clearly understand your current
situation, please complete the following
Scorecard.
Rate your level of confidence
form 1-10, with “1” being the lowest and
“10” being the highest.
1 2 3 4 5 6 7 8 9 10
1. How confident are you that your employees are getting
1 2 3 4 5 6 7 8 9 10
the right medical treatment when injured?
2. How confident are you that your injured employees
1 2 3 4 5 6 7 8 9 10
are returning to work and back to full productivity as
soon as possible?
3. How confident are you that you are hiring employees
1 2 3 4 5 6 7 8 9 10
that meet the physical demands of the Job?
4. How confident are you that you understand all the
1 2 3 4 5 6 7 8 9 10
costs the insurance company does not pay when an
employee gets injured?
5. How confident are you that your Supervisors are
1 2 3 4 5 6 7 8 9 10
aware of their role before and after an injury occurs?
6. How confident are you that your Experience
1 2 3 4 5 6 7 8 9 10
Modification Factor is free from errors?
7. How confident are you that you know how to manage
1 2 3 4 5 6 7 8 9 10
your Experience Modification Factor to the minimum?
8. How confident are you that you understand the risk
1 2 3 4 5 6 7 8 9 10
and dangers that an increasing Experience Modification
Factor poses to your business?
9. How confident are you that you are not being
1 2 3 4 5 6 7 8 9 10
overcharged on your premium audit?
10. How confident are you that you are in compliance
1 2 3 4 5 6 7 8 9 10
with federal and state safety requirements?
11. How confident are you that your safety programs
1 2 3 4 5 6 7 8 9 10
are reducing injuries?
12. How confident are you that you are in compliance
1 2 3 4 5 6 7 8 9 10
with Federal Worker’s Compensation Acts?
13. How confident are you that your company has
1 2 3 4 5 6 7 8 9 10
coordinated WC, Group Health, FMLA, COBRA and ADA?
WorkComp Self Assessment
________________________________________
To more clearly understand your current
situation, please complete the following
Scorecard.
Rate your level of confidence
form 1-10, with “1” being the lowest and
“10” being the highest.
1 2 3 4 5 6 7 8 9 10
1. How confident are you that your employees are getting
1 2 3 4 5 6 7 8 9 10
the right medical treatment when injured?
2. How confident are you that your injured employees
1 2 3 4 5 6 7 8 9 10
are returning to work and back to full productivity as
soon as possible?
3. How confident are you that you are hiring employees
1 2 3 4 5 6 7 8 9 10
that meet the physical demands of the Job?
4. How confident are you that you understand all the
1 2 3 4 5 6 7 8 9 10
costs the insurance company does not pay when an
employee gets injured?
5. How confident are you that your Supervisors are
1 2 3 4 5 6 7 8 9 10
aware of their role before and after an injury occurs?
6. How confident are you that your Experience
1 2 3 4 5 6 7 8 9 10
Modification Factor is free from errors?
7. How confident are you that you know how to manage
1 2 3 4 5 6 7 8 9 10
your Experience Modification Factor to the minimum?
8. How confident are you that you understand the risk
1 2 3 4 5 6 7 8 9 10
and dangers that an increasing Experience Modification
Factor poses to your business?
9. How confident are you that you are not being
1 2 3 4 5 6 7 8 9 10
overcharged on your premium audit?
10. How confident are you that you are in compliance
1 2 3 4 5 6 7 8 9 10
with federal and state safety requirements?
11. How confident are you that your safety programs
1 2 3 4 5 6 7 8 9 10
are reducing injuries?
12. How confident are you that you are in compliance
1 2 3 4 5 6 7 8 9 10
with Federal Worker’s Compensation Acts?
13. How confident are you that your company has
1 2 3 4 5 6 7 8 9 10
coordinated WC, Group Health, FMLA, COBRA and ADA?
WorkComp Self Assessment
Confidential questionnaire
_____________________________________
1. In the last five years has the ownership of your business changed or have
you acquired or merged with another business entity?
2. Are your sub-contractors part of an employee leasing arrangement?
3. Do your employees travel out of state?
WorkComp Self Assessment
Confidential questionnaire
_____________________________________
4. Do you have out-of-state locations?
5. Are any corporate officers excluded from workers’ compensation coverage?
6. (Contractors only) Do you participate in owner controlled insurance plans
(wrap-ups) or prevailing wage jobs (Davis-Bacon Act)?
WorkComp Self Assessment
Confidential questionnaire
_____________________________________
7. What progress have you already made in improving your workers’
compensation program?
8. What obstacles have you faced in addressing your workers’ compensation
program?
If you would like to discuss your answers or our
questions, please just e-mail this form back to us with
a time to reach you.