Company Name:

Address:

Number of employees at your company?

Contact:

Number of injuries per year?

Phone/Fax No.

Frequency of service calls from WorkWell?

E-mail:

Second Contact/Phone:

Special Contact/Phone:

Other Locations for your company/how many list or all attach list of locations:

Insurance Carrier Information:

Address:

Effective Date & Renewal Date:

Contact & Phone:

Quality of care by WorkWell: