New Enrollment Form printable pdf download

New Enrollment Form

OHIO SAFETY COUNCIL

NEW ENROLLMENT FORM

In an effort to reduce the number of workplace accidents and to share resources and

information on accident prevention, risk management and workers' compensation in

Ohio, BWC's Division of Safety & Hygiene and your local safety council co-sponsor

this service.

In signing this enrollment form, the employer makes a commitment to

send representatives to the majority of safety council meetings and to submit semi-

annual reports by the deadline dates.

Enrollment date ___________________

Company name ___________________________________________________

Address _________________________ City _________________ Zip ______

Phone number _________________________

FAX #___________________

E-mail address ___________________________________________________

Average number of employees _______________

Type of work _____________________________________________________

BWC policy number_________________________

Printed name _____________________________________________________

Title ____________________________________________________________

Signature ________________________________________________________

Safety Council Account Number

To Be Completed by the Safety Council of Northwest Ohio before submitting to DSH

_____________________________ / ____ ____ / ____ ____ / ____ ____

Revised 6/09

New Enrollment Form