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WHS New Client Form
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WHS New Client Form
Company Name
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
(Required)
Fax Number
(Required)
Number of Employees
(Required)
What does your company do?
(Required)
What type of shifts and hours do your employees normally work?
(Required)
Do you hire through a staffing agency?
(Required)
Yes
No
If so, who do you currently partner with?
DER - Designated Employer Representative (Required)
Name
(Required)
First
Last
Position
(Required)
Email
(Required)
Direct Phone
(Required)
Cell Phone
(Required)
Secondary Contact Information (Optional)
Name
First
Last
Position
Email
Direct Phone
Cell Phone
Tertiary Contact Information (Optional)
Name
First
Last
Position
Email
Direct Phone
Cell Phone
Would you like to add a fourth contact?
Yes
No
Fourth Contact Information (Optional)
Name
First
Last
Position
Email
Direct Phone
Cell Phone
Would you like to add a fifth contact?
Yes
No
Fifth Contact Information (Optional)
Name
First
Last
Position
Email
Direct Phone
Cell Phone
Accounts Payable Information (Required)
Contact Name
(Required)
First
Last
Phone Number
(Required)
Fax
(Required)
Email
(Required)
Accounts Payable Email
(Required)
*Invoices will be emailed to ACCOUNT PAYABLE EMAIL*
Workers' Compensation Information
Work Comp Broker
Company Name
Risk Manager
First
Last
Phone Number
Email Address
Workers' Compensation Insurance Carrier
Insurance Company
(Required)
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Policy Number
(Required)
Expiration Date
(Required)
MM slash DD slash YYYY
Please select all services that are needed/interested in:
Unique WHS Services
(Required)
Workers’ Compensation Injury Treatment
WHS Afterhours Services: 24/7 Substance Abuse Testing (We come to you)
WHS Afterhours Services: 24/7 Telephonic Triage
WHS Afterhours Services: 24/7 Injury Care
Recent Use THC Testing Services - Workday Use Detection
National Medical Triage Services
DOT / NON-DOT Random Drug Testing Management Services
Safety and Environmental Services
Human Resources Consulting and Training
Other/None
Other:
Pre-Employment / Post Offer Testing
(Required)
Background Screening Services
DOT / NON-DOT Drug / Alcohol Testing
DOT / NON-DOT Physical Exams
Respiratory Testing
Audiometric Testing
Vision Testing
Other/None
Other:
Onsite Services
(Required)
Annual Audiometric Testing
Annual Respiratory Testing
Annual Vision Testing
Annual Surveillance Physical Exams / Labs
Monthly/Quarterly Random Drug Testing
Bus Driver / DOT Exams
Annual Wellness Events
Flu Shots
Other/None
Other:
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