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["WORKPLACE SAFETY AWARDS"]
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[null,"Great West Casualty Company's Workplace Safety Awards (WSA) are based on a motor carrier's work-related incidents (injuries and illnesses) from the previous calendar year. To be eligible for an award, you must:                                                    1. Be a current Great West insured with workers compensation (WC) coverage,                                                                                                                                           2. Have five (5) or more employees, and                                                                                                                                                         3. Have had WC coverage with Great West for at least nine months of the previous calendar year. "]
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[null,null,"INSTRUCTIONS: Submissions are due by March 1 each year. Complete all fields in RED. Use the TAB key to move between fields. When finished, print the form and email or fax it to your Great West Safety Services department listed below. You may re-use this electronic form each year.            "]
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[null,null,"STEP 1:","ENTER THE PREVIOUS CALENDAR YEAR."]
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[null,null,"STEP 2:","ENTER THE TOTAL NUMBER OF WORKPLACE INCIDENTS FROM THE PREVIOUS CALENDAR YEAR."]
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[null,null,"STEP 3:","ENTER THE TOTAL NUMBER OF EMPLOYEE HOURS WORKED IN THE PREVIOUS CALENDAR YEAR."]
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[null,null,"INCIDENT FREQUENCY RATE = ",null,null,null,null,null,null,null,{"$f":"(K10*200000)/K12","v":{"$error":"#DIV/0!"}}]
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[null,"COMPANY"]
[null,null,null,null,"Enter your company name in ALL CAPS as you want it to appear on your award. \n"]
[null,"WC POLICY #"]
[null,"CONTACT",null,null,null,null,null,null,"PHONE"]
[null,"STREET"]
[null,"CITY, STATE",null,null,null,null,null,null,null,"ZIP"]
[null,"EMAIL"]
[null,null,"Note: Designating an incident as “preventable” does not constitute an admission of any liability with regard to any claim presented that arises from the incident.                                         \n"]