Kansas.gov

Instructions for Completing Year End Accident Prevention Report (K-ISH 28)



Section IItem 1Enter the company's NAIC number (User Name), then the Accident Prevention ID number (password) shown at the top of the letter (email subject line) sent each year to each insurance company or for  group-funded self-insurance plans the internal numbers assigned by the Kansas Department of Insurance. A specific AP ID number has been assigned to each since approximately 2006; it has not and will not change each year.
Item 2Indicate the name of the insurance company or group-funded self-insurance plan that is assuming direct liability on the contract/certificate for workers compensation contracts (policies)/certificates delivered or issued for delivery in this state, as filed with the Kansas Insurance Department
Item 3Address of insurance company or group-funded self-insurance plan on which this report is being filed.
Item 4List name, title, phone number and email address of person who is responsible for completion of report.
 
Section IIItem 1 Check appropriate box indicating whether insurance company or group-funded self-insurance plan provided workers compensation insurance to policyholders with Kansas exposures. If you check NO, you will be directed to Section IV to answer YES or NO. After you have checked one of the two boxes you will then be directed to the Affirmation section to complete the form. If you check YES you must complete each section of the report form.
 
Section IIIItem 1Total amount spent on accident prevention services, including all accident prevention services, travel, materials, salaries, contracted services, etc. Do not include underwriting visits to policyholder’s premises unless accident prevention services were provided during the visit. In this case, pro-rate the services accordingly.
 
Section IVItem 1Even if a policyholder has not requested a service, this section must be filled out. The statute states; “Each insurance company or group-funded self-insurance plan providing workers compensation insurance coverage in Kansas shall maintain and shall provide accident prevention programs upon request of the covered employer as a prerequisite for authority to provide such insurance or coverage.…The insurance company or group-funded self-insurance plan may employ qualified personnel, retain qualified independent contractors, contract with the policyholder to provide qualified accident prevention personnel and services, or use a combination of such methods to fulfill the obligations imposed by this section. Accident prevention personnel shall have the qualifications required for field safety representatives.” We want to ensure that if a service is provided, the person or persons providing the service, whether as a company employee, third party or the policyholder, is qualified. After entering the name of the individual provider and their affiliation, select one of the items which qualifies the listed field safety representative. If item #8 is used, provide documentation showing the Secretary of the Department of Labor’s approval. If none of the qualifiers are applicable, contact the Accident Prevention Coordinator at (785) 484-3539 or email steve.lolley@dol.ks.gov. For multiple entries, fill in the name, affiliation and qualifications of each individual and click the "Enter or Add Name/Affiliation" on the bottom right after each entry. Entries that have been successfully added will be displayed in a list below the "Enter or Add Name/Affiliation" button.
 
Section VColumn 1Breakdown of policy premiums according to KSA 44-5, 104 (d)(5). Enter only whole numbers.
Column 2Number of policies or certificates issued during the fiscal year in each indicated premium category. Enter only whole numbers.
Column 3Number of visits, requested and non-requested, where accident prevention services were provided to Kansas policyholders during the fiscal year in each indicated premium category. (The total for items under Section V and the total of items under Section VI should match.) Enter only whole numbers.
Column 4Total amount of workers compensation premiums written during fiscal year on policies with exposures in Kansas after any adjustments or discounts are applied (experience modifiers, etc.) in each indicated premium category. Enter only whole numbers.
Column 5Total amount of money paid out on claims for the fiscal year in each indicated premium category. Enter only whole numbers.
 
Section VIItem 1Check appropriate box indicating whether your insurance company or group-funded self-insurance plan maintains and provides upon request accident prevention services to policyholders with Kansas exposures. (This should always be yes.)
Item 2Total number of policyholder-requested on-site safety related inspections performed by qualified field safety representatives, either company or group employed or contracted, during the fiscal year in all indicated premium categories.
Item 3Total number of policyholder-requested on-site industrial hygiene and health related studies performed by qualified field safety representatives, either company or group employed or contracted, during the fiscal year in all indicated premium categories.
Item 4Total number of policyholder-requested on-site training programs or materials provided by the company or group to Kansas employers during the fiscal year in all indicated premium categories.
Item 5Total number of non-requested on-site company or group safety related inspections, industrial hygiene and health-related studies, and training programs or materials that were provided to Kansas employers during the fiscal year in all indicated premium categories.
NOTE: The total amount in Section V, column 3 should match with the totals of Items 1, 2, 3, and 4 in Section VI.
 
Section VIIItem 1Using the link found in this section, download the Excel spreadsheet to your computer and complete it. Please do not use an old copy of the spreadsheet, as the template has changed this year. You must fill in your assigned Accident Prevention ID number and the name of the insurance company or group-funded self-insurance plan as filed with the Kansas Insurance Department. You will have to submit a separate Excel spreadsheet for each company in your fleet or group. Once completed, go back to the K-ISH 28 form, hit the browse button and upload to the form by clicking the "Click Here to Upload File" button. Please upload only one Excel spreadsheet per APID. If you need to submit an amended Excel spreadsheet, simply upload the amended file, and it will overwrite the file previously uploaded. The file cannot exceed 7MB in size and you cannot have the file open in Excel when you attempt to upload the file. If your file exceeds 7MB in size, or you require more than 10,000 lines in your spreadsheet, you will have to mail your spreadsheet on a CD to the Accident Prevention Coordinator. You will not be able to submit your report until your spreadsheet is copied from your CD to our server. With the increase in maximum file size to 7MB and the expansion of the spreadsheet template to 10,000 lines, we do not anticipate any company needing to submit their spreadsheet(s) on CD. Provide the following information for each policyholder that was issued a workers compensation insurance policy or certificate during the report’s fiscal year:

a. Policyholder written premium for fiscal year.
b. *1 Indicate by using an R which policyholders requested accident prevention services and indicate by using an N policyholders who were provided non-requested services from your company or group-funded self-insurance plan during the fiscal year (July 1 to June 30).
c. List employer’s business name.
d. List address, city, state and ZIP code of business.
e. (**2) Total number of claims/injuries filed by the business during fiscal year.
f. Experience modifier applied to premium during fiscal year.
(*1) Total of AP requested/non-requested in column (B) should match total of Section VI - 1, 2, 3 and 4.
(**2) Provide the number of claims/injuries filed during the fiscal year.
 
Section VIIIItem 1Check appropriate box indicating whether or not third-party contractors were utilized in providing accident prevention services to policyholders requesting these services.
Item 2If Yes box was checked, provide the information using the drop down form. (For multiple entries, each time you fill in the information for an independent or third-party contractor, enter your information into the form, click the "Enter or Add Contractor" button at the bottom right and repeat until completed.) Entries that have been successfully added will be displayed in a list below the "Enter or Add Contractor" button.
 
Section IXItem 1Check appropriate box indicating affiliation with a group, consolidated group or consolidated fleet.
Item 2If Yes box was checked, complete the information using the drop down form. (For multiple entries, each time you fill in the information for a fleet, enter your information into the form, click the "Enter or Add Fleet" button at the bottom right and repeat until completed.) Entries that have been successfully added will be displayed in a list below the "Enter or Add Fleets" button.
 
This form must include an electronic signature of an insurance company or group-funded self-insurance plan representative, their title and the date. The form cannot be submitted until the policy holder list spreadsheet has been uploaded to Section VII. A confirmation screen that says "Thank you for complying with K.S.A. 44-5 104(d) by completing the Year-End Accident Prevention Report conducted by the kansas Department of Labor Division of Industrial Safety and Health" will be displayed if your submission was successful. If you don't get this confirmation screeen, please email the accident prevention coordinator, including screen prints of any messages from the system.
 
The submission must be received by KDOL/ISH no later than August 31. Late submissions may be referred to the Commissioner of Insurance to consider assessment of administrative violations and penalty pursuant to K.S.A. 40-2, 125. You may request an extension of time by emailing the KDOL accident prevention coordinator.