EmailMeForm
New Employer Registration
Complete registration to become a new client
1
2
▶
1
2
Employer Information
Employer/Company Name
Physical Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Billing Information
Employer/Company Billing Address for Contract Services
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Billing Contact Name
*
Phone
*
###
-
###
-
####
Workers Compensation Insurance Company
Phone
###
-
###
-
####
Designated Employer Representatives
List the designated employer representative along with any other person(s) that can authorize treatment.
Name
*
First
Last
Title
*
Email
Phone
*
###
-
###
-
####
Name
First
Last
Title
Email
Phone
###
-
###
-
####
Services
Check all services that we will provide to your company
*
COVID Testing
DOT Physical
Non-DOT Physical
Vaccinations
Worker's Compensation - Initial Injuries Only
1
/
2
