Customer Information Form

(Items Bolded are required)

Company Name:

Company Address:

            City/St/Zip:

Contact Person:    Phone:   E-Mail:

Alternate Contact:    Phone:    E-Mail:

Company Fax No.:

How many employees does your company have?

How many injuries do you average per month?

Do you provide light-duty work for injured employees? Yes No

Do you provide or make available annual flu shots for your employees and/or their families? Yes No

Which of the following pre-placement services does your company require?

Non DOT Physical	DOT Physical	Tuberculosis Screening
Non DOT Drug Screen        Drug Screen Panel: 5 8 10	DOT Drug Screen	Hepatitis-B Vaccine
Random Drug Screen	Breath/Alcohol Test	Lead Testing
Hearing Testing	Spirometry	Other:
Back X-Rays	WorkSTEPS®

What is the name of your health insurance company?

 

Worker's Compensation Information What is the name of your Worker's Compensation carrier? W/C Address: Phone:      City/St/Zip:      Fax:   Adjuster's Name:   TWCC or Third Party Adjuster

Who should we submit invoices to?