SEMI-ANNUAL REPORT

Semi-Annual Report

You can complete the online form below or send your form by any of the methods listed on our CONTACT page.

Click here to download the instruction form.

* Indicates required field

For what year are you reporting? *

For which Half of the year are you reporting? *

BWC Policy Number *

Company Name: *

Street Address *

City *

State *

Zip Code *

Phone Number *

Fax Number *

Submitted By *

*Name of Person Completing this Form

E-mail *

Date: *

Has information provided above been updated on this report? *

Yes No

1.) Date of MOST RECENT injury or illness resulting in day(s) away from work: (mm/dd/yyyy) *

Report All Information Below For CURRENT SIX MONTH PERIOD ONLY (corresponds with period identified above)

2.) Average Number of Employees: *

Additional Comments *

3.) Total Hours Worked (entire six month period, all employees) *

Additional Comments *

Items 4, 5, & 6 are based on the Recordkeeping Requirements under the Occupational Safety & Health Act of 1970.

The questions listed below correspond to the columns in the OSHA 300 Log/PERRP Form 300P.

4.) Number of Deaths *

* (column G in the OSHA 300 Log/PERRP Form 300P)

5.) Number of occupational injuries and/or illnesses resulting in days away from work *

6.) Number of days away from work as a result of occupational injuries and/or illnesses *

* (column K in the OSHA 300 Log/PERRP Form 300P)

Note: If you report a death, injury or illness resulting in days away from work in the current six month period (item 4 or 5), the most recent date of death, injury or illness must correspond with item 1.

Submit

HOME PAGE