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Click ‘Get Form’ to open the FAX: 615-253-5265 application in the editor.
Begin by selecting whether this is a new application, renewal application, or if you have changed your insurance carrier. Circle the appropriate option.
Fill in your company name and FEIN (Federal Employer Identification Number) in the designated fields.
Complete the mailing and business address sections, ensuring all information is accurate and legible.
Provide your contact details including phone number, fax number, and email address.
Enter the name of your Substance Abuse Program Administrator and describe the nature of your business along with the total number of full-time and part-time employees.
Indicate your Workers’ Compensation Insurance Carrier and provide lab certification details as required.
Answer questions regarding employee training on substance abuse policies with 'Yes' or 'No'.
For renewal applicants, fill in the number of tests performed in various categories over the past 12 months.
Finally, ensure that you sign and date the form at the bottom before submitting it to ensure compliance with all requirements.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (81 Votes)
2016	4 Satisfied (39 Votes)

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