Comprehensive Year-End Declaration for Workers' Compensation & Liability Policy Renewal

1. Policyholder & Business Classification Identifiers

Provide accurate identification and classification details for the policyholder entity. All fields marked as mandatory must be completed to ensure proper policy matching and risk assessment.

Legal Entity Name

Trade Name (DBA)

Primary Policy Number(s)

Policy Period Start Date

Policy Period End Date

Corporate Risk Officer Full Name

Risk Officer Official Title

Risk Officer Direct Email

Risk Officer Contact Phone

Primary Business Classification Code

Have there been any changes to the legal entity structure during the policy period?

Yes

No

Describe the structural changes including mergers, acquisitions, divestitures, or reorganization:

Has the company undergone any name changes or rebranding during this period?

Yes

No

Provide previous names and effective dates of change:

Have there been significant changes to primary business operations or services offered?

Yes

No

Detail the operational changes and their effective dates:

2. Annual Payroll & Contractor Disbursement Breakdown

Declare complete and accurate payroll data by classification. Include all employee compensation and third-party contractor disbursements. Significant variances from prior year declarations will require detailed explanation.

Total Annual Payroll (excluding contractors)

Payroll Distribution by Classification Code

	Classification Code	Classification Description	Annual Payroll Amount	Number of Employees	Overtime Payroll	Bonus & Commission Payroll
	A	B	C	D	E	F
1
2
3
4
5
6
7
8
9
10

Total Overtime Payroll (all classifications combined)

Total Bonus & Commission Payroll (all classifications combined)

Has total payroll increased or decreased by more than 15% compared to the prior policy period?

Yes

No

Explain the primary factors causing this significant payroll variance including workforce expansion, reduction, wage adjustments, or operational changes:

Total Third-Party Contractor Disbursements (1099 or equivalent)

Contractor Disbursements by Service Type

	Service Type	Contractor Classification	Total Disbursement	Number of Contractors	Certificate of Insurance Obtained
	A	B	C	D	E
1
2
3
4
5
6
7
8
9
10

Payroll Allocation Method Used

Actual Hours Worked by Classification

Percentage Estimation Based on Duties

Peak Season Weighted Average

Standard Split Ratio

Other Method

Do any employees split time between multiple classification codes?

Yes

No

Describe the split-time arrangements and allocation methodology:

3. High-Risk Job Classification & Exposure Changes

Identify and quantify any changes to high-risk job classifications, operational exposures, or work environments that may impact risk assessment and premium calculation.

Have any new high-risk job classifications been added during this policy period?

Yes

No

New High-Risk Classifications Added

	Classification Code	Job Description	Number of Employees	Associated Payroll	Effective Date Added
	A	B	C	D	E
1
2
3
4
5
6
7
8
9
10

Has the number of employees in existing high-risk classifications changed by more than 20%?

Yes

No

Specify the classification codes and explain the reasons for the significant employee count change:

Has the company commenced any new operations, services, or product lines?

Yes

No

Describe the new operations, associated risks, and implementation timeline:

Have there been any new geographic exposures including international operations or remote work expansions?

Yes

No

List new geographic locations, jurisdictions, and approximate employee counts per location:

Have new physical or environmental hazards been introduced to the workplace?

Yes

No

Detail the new hazards, affected employee classifications, and mitigation measures implemented:

Has there been significant changes to work schedules including shift work, overtime hours, or seasonal patterns?

Yes

No

Explain the schedule changes and their risk implications:

Has the company acquired new equipment, machinery, or vehicles that alter operational risk?

Yes

No

Describe the equipment, its usage, and associated employee classifications:

Were there any reportable incidents, claims, or near-miss events during this period?

Yes

No

Incident & Claim Summary

	Incident Date	Classification Code	Incident Description	Number of Affected Employees	Resulted in Claim?	Claim Reserve Amount
	A	B	C	D	E	F
1
2
3
4
5
6
7
8
9
10

4. Safety Program & Loss Control Credits Check

Evaluate and document the organization's safety management systems, loss control initiatives, and eligibility for premium credits or discounts based on risk mitigation efforts.

Does the organization maintain a formal, written safety and health program?

Yes

No

Briefly describe the program scope, objectives, and governance structure:

Explain the absence of a formal program and any alternative risk management approaches:

Total Annual Safety Training Hours (all employees combined)

Is there a designated safety committee or safety officer position?

Yes

No

Safety Committee Meeting Frequency

Rate the effectiveness of the following safety program components (1=Poor, 5=Excellent)

	Poor	Fair	Average	Good	Excellent
Management Commitment
Employee Participation
Hazard Identification
Training Quality
Incident Reporting Culture
Corrective Action Follow-through

Upload supporting documentation for loss control credits (certificates, audit reports, program descriptions)

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Have there been any modifications to the safety program during this policy period?

Yes

No

Describe the modifications, rationale, and implementation timeline:

Total Recordable Incident Rate (TRIR) for this period

Total Annual Investment in Safety Programs & Equipment

5. Chief Financial Officer & Auditor Verification Sign-Off

Final verification and attestation by authorized financial leadership and independent audit confirmation. This section requires official signatures and supporting documentation to validate the accuracy of all reported data.

Chief Financial Officer Full Name

CFO Official Title

CFO Digital Signature

CFO Signature Date

Independent Auditor Firm Name

Auditor Report Date (if applicable)

I hereby certify that the payroll and exposure data reported herein has been reviewed against official company financial records and is accurate to the best of my knowledge.

I confirm that all contractor disbursements have been properly classified and reported in accordance with applicable insurance reporting standards.

I attest that the information regarding high-risk classifications and operational changes is complete and transparent.

I acknowledge that material misrepresentation or omission of facts may result in policy cancellation or premium adjustment.

Upload Audited Financial Statements or Review Report supporting the payroll figures declared

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Upload General Ledger Payroll Summary or Certified Payroll Register

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Were there any material audit findings related to payroll or employee classification?

Yes

No

Summarize the audit findings and corrective actions taken:

By submitting this form, the undersigned certifies that all information is true, complete, and accurate. The organization agrees to notify the insurer of any material changes that occur after submission but before policy renewal.