BWC Semi-Annual Report Form

Please fill out the form by the required BWC deadline dates of July 15, 2019 (1st Half Report - January 1 thru June 30, 2019) and January 15, 2020 (2nd Half Report - July 1 thru December 31, 2019).

If your company’s reports are not submitted by the deadline, your company will not be eligible for the BWC Rebate Program or Safety Campaign.

Click here to review The BWC Safety Council Rebate Program eligibility requirements.

Print Out a PDF of the Semi-Annual Report Form and Instructions

2019 SEMI-ANNUAL REPORT FORM

REQUIREMENT FOR BWC REBATE & AWARDS!

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Semi-Annual Report Data for: (Required)

Safety Council Account Number (BWC Risk Number): (Required)

Company Name: (Required)

Contact Person: (Required)

Title of Contact Person: (Required)

Company Address: (Required)

Street Address

Address Line 2:

City: (Required)

State: (Required)

Zip Code: (Required)

Contact Email: (Required)

Phone Number: (Required)

Contact Phone Number

Fax Number: (Required)

Company Fax Number

Date of Submission:

1. Last Injury or Illness resulting in a full day(s) away from work:

This is the date of the most recent injury that resulted in an employee missing at least one full day of work. For the 1st Half of 2018, this date must be between January 1 and June 30, 2018. For the 2nd Half of 2018, this date must be between July 1 and December 31, 2018. The date does not necessarily have to be during this reporting period, if no injuries occurred. If you have not previously reported an injury on this form please use 01/01/1900.

2. Average Number of Employees: (Required)

Please Include Full-Time, Part-Time & Temporary Employees

3. Total Hours Worked: (Required)

Total Hours for the Entire Six Month Period for All Employees. Multiply the average number of employees x the average number of hours worked per week x the number of weeks in the six-month period. (i.e. 725 employees x 40 hours = 29,000 hours x 26 weeks in the six month period = 754,000 hours).

4. Number of Deaths: (Required)

You May Use Your OSHA 300 Log

5. Number of Injuries resulting in day(s) away from work: (Required)

Number of occupational injuries and/or illnesses resulting in days away from work. You may use your OSHA 300 Log. NOTE: Everyone does not keeps a OSHA 300 log. If you entered a date in the last illness or injury box for the current 6 month period you must enter a number here, there should be at least a 1.

6. Days Away from Work: (Required)

Number of days away from work as a result of occupational injuries and/or illnesses. You may use your OSHA 300 Log. If you entered a date within the current 6 month reporting period in the last illness or injury box you must enter a number here, there should be at least a 1. If the date of last injury or illness resulting in days away from work was during a previous six-month period, (5) and (6) should be 0 unless an employee is still having lost days as a result of a previous injury (then there may be a number on line 6). NOTE: If the days away from work resulted from an accident which occurred in a previous six-month period, please report the additional workdays missed.

Please check here if information provided above has been updated on this report.

Updated Report

Your Name:

First Name

Last Name

Your Email: (Required)

Members Area

BWC Semi-Annual Report Form

2019 SEMI-ANNUAL REPORT FORM

REQUIREMENT FOR BWC REBATE & AWARDS!

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