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Comoros
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Burkina Faso
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Cape Verde
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Cayman Islands
Central African Republic
Ceuta & Melilla
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
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Congo - Kinshasa
Cook Islands
Costa Rica
Croatia
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Curaçao
Cyprus
Czechia
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Denmark
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Fiji
Finland
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Georgia
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Ghana
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Greenland
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Jersey
Jordan
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Kenya
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Mayotte
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Namibia
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Nepal
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New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
North Macedonia
Norway
Oman
Outlying Oceania
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Samoa
San Marino
Sark
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Senegal
Serbia
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Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Helena
St. Kitts & Nevis
St. Lucia
St. Martin
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Sweden
Switzerland
Syria
São Tomé & Príncipe
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tristan da Cunha
Tunisia
Turkmenistan
Turks & Caicos Islands
Tuvalu
Türkiye
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Uganda
Ukraine
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United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Would you like your WC Invoices billed to
Your company
Directly to your carrier
Services Needed
Services Needed
Injury Care
TB Testing
Pre Placement Physicals
DOT Physicals
Pre-Placement Physicals to Include
Physical Exam
Urinalysis
Drug Testing
Pulmonary Function Testing
Vaccination (Hep B)
BAT (Breath Alcohol Testing)
Drug tests needed
Drug Screening Information (if applicable)
Services Needed (check all that apply)
DOT Panel (Drug screening)
Non-DOT Instant Urine (Point of Care Testing)
5-Panel (Rapid Drug Screening)
10-Panel (Rapid Drug Screening)
Do you Have a Third Party Administrator for Your Company's Drug Screening Program
Yes
No
Name of Your 3rd Party Administrator
Please answer the following questions to the best of your ability
How many employees does your company currently have?
Average new employees hired each year?
How many drug/alcohol tests does your company average per year?
What is your average number of injuries per year?
How many DOT/Pre-Employment physicals do you perform in a year?
Occupational Injury
Please check all testing you would like performed in the event of an occupational injury
Occupational Injury Services Needed
DOT Drug Screen
5-Panel Rapid Drug Screen
10-Panel Rapid Drug Screen
Breath Alcohol Testing (BAT)
TB Test
Pulmonary Function Test (PFT)
None
How would you like to receive employee results?
Fax
Email/Employer Portal
Secure fax line
Address
Please write any additional information we may need
New Hire/Pre-Employment
Please check all testing you would like performed during new hire/pre-employment
New Hire/Pre-Employment
DOT Drug Screen
5-Panel Rapid Drug Screen
10-Panel Rapid Drug Screen
Breath Alcohol Testing (BAT)
TB Test
Pulmonary Function Test (PFT)
None
How would you like to receive employee results
Fax
Email/Employer Portal
Secure Fax Line
Address
Please write any additional information we may need
Submit