Colorado Emergency Services Association

3005 Center Green Drive, Suite 120, Boulder, CO 80301 Phone: 303-444-4666 - Fax: 303-444-8481 ANNUAL SAFETY GROUP COMPLIANCE REPORT All members of the Colorado Emergency Services Association Safety Group are required to comply with the following criteria to remain an active member of CESA and to continue to receive the 4% safety group premium discount on your organization’s Pinnacol Assurance workers’ compensation insurance policy.

New Requirements for All CESA Safety Group Members Completed 1. A lower maximum loss ratio requirement – less than 55% net uncapped loss ratio in either: 3 out of the 4 most recent complete group years; OR cumulatively using up to the 4 Yes____ No____ most recent complete group years. Don’t Know ____ 2. Written policies and implementation of: - Claims management program Yes____ No____ - Return-to-work program, including modified duty offers to eligible paid workers Yes____ No____ - Development and implementation of worker safety programs Yes____ No____ - Effective hiring practices Yes____ No____ Utilization of medical providers in the Pinnacol SelectNet provider network - Yes____ No____ (with a 30 mile rural exemption), and providing required provider notices to all covered workers Yes____ No____ - Health, fitness and wellness policies Yes____ No____ - Job hazard analysis for training activities Yes____ No____ - Post-accident investigation of all accidents, incidents and/or near misses Yes____ No____ If you answered Yes above, please provide copies of your organization’s policies. If you answered No above, would you like us to send you sample policies? 3. Completion of the year-end premium audit of your policy for the previous policy period by Pinnacol Assurance, and payment of any audit premium adjustments that are Yes____ No____ assessed. 4. Mandatory participation in minimum of 2 approved safety training classes per year specific to the safety group’s program and pre-approved by Pinnacol Assurance.

Have 1 or more members of your organization attended or participated in at least 2 Pinnacol Yes____ No____ approved workers’ compensation loss control or worker safety training programs in 2014 that were conducted and/or sponsored by Pinnacol Assurance and/or by CESA and VFIS? Name of Program(s): ______Date of Program(s): ______Name of Participant(s): ______Yes____ No____ If you answered No above, would you like us to send you information on upcoming Pinnacol- approved trainings programs? 5. Has your organization received the Cost Containment Certification from the Colorado Department of Labor? Yes____ No____ If yes, date of most recent certification: ____/____/_____ – ____/____/_____

Date: ____/____/______Signed By: ______Phone: (_____) ______-______Organization Name: ______Pinnacol Policy #: ______

THIS FORM MUST BE RECEIVED BY CESA NO LATER THAN OCTOBER 31st