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Name of employee's employer Policy/Plan Number Name of Employer Employee ID Employee Social Security Number Employer State of Residence 2. Is Employee a: Full-time or part-time employee Paid FTE or part-time employee Self-employed? 3. What did the employee do for the most part? 4. How many hours a week do Employee's hours vary from week to week? 5. How long have the Employee's employment contract with Employer been? 6. Have Employee's employment contract or other contracts with any other corporations or organizations been changed in any way? 7. Did Employer or any employer with whom Employee was currently doing business at the time of the incident have any involvement with the incident? Employer's relationship to Employee at the time of the incident 8. Was it/he/she Employer's (or any employer's) policy? 9. Was it/him/her Employer's decision to continue or discontinue the employee's participation in this program? 10. After you make these changes to Employee, are there any other related actions that are necessary? 11. What is the Employer's (or any employer) liability if something happens while Employee is working under the Employee's contract, policy or plan? The policy or plan should be consistent with all applicable laws and regulations. This policy or plan must satisfy all conditions set forth in the appropriate provisions of the Policies and Procedures Manual. Failure to maintain employment contract or other contract with the employee shall not limit the coverage of any other insurance that Employee may have and any claim against the Employer for work-related injuries or illnesses.