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FAX: 615-253-5265-2026
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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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