Company Employer Contact Information and Occupational 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Company Name, Local Address, City, State, Zip Code, Phone, and Fax in the designated fields. Ensure all information is accurate for effective communication.
3. If your billing address is the same as the local address, check the 'same as above' box. Otherwise, fill in the separate Billing Address fields.
4. Provide details for a Contact Person including their Phone, Fax, and Email. This ensures that inquiries can be directed appropriately.
5. Select your Preferred Method of Contact by checking one of the options: Email, Confidential fax line, or Mail.
6. Indicate any Occupational Medicine/Wellness Services you require by checking the relevant boxes. This helps tailor services to your needs.
7. Complete any additional sections related to Pre-Employment Occupational Medicine Services and Post-accident Required Testing as applicable.
8. Finally, review all entered information for accuracy before submitting via fax or email as indicated at the bottom of the form.

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