To set up an account with Workplace Health as your company's preferred provider please complete the following information.
Workplace Health Company Profile:
* indicated a required field. Completed By:* Date: Company Name: Mailing Address: Address (line 2): City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:
Contact Person:
First Name: Last Name: Title: Phone: Ext: Fax: Email: (Workplace Health sends out an opt-out newsletter approximately every 6 weeks.)
Company Type:
Manufacturing Construction Transportation/Warehouse Healthcare/Residential Care Retail Marine Education Fed/State Government Municipality Office/Call Center/Finance Other
Number of Employees: Are you an MMTA member? Yes   No How did you hear about Workplace Health?
Billing Information:
Click here if billing address is the same as above. First Name: Last Name: Title: Phone: Ext: Mailing Address: Address (line 2): City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:
Insurance Information:
Phone: Ext: WC Carrier: Claims Adjuster: Phone: Ext: Mailing Address: Address (line 2): City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:
Services Requested:
Initial Injury Assessment Drug & Alcohol Testing Injury Follow-up DOT Drug & Alcohol Consortium (random pool) Preplacement Screenings Other Our company is interested in learning more about Wokrplace Health, please call us.
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