Enrollment Form

We are in accord with an effort to reduce the number of accidents occurring to our employees and desire to enter our company in the Safety Council program, beginning Jan.1 and ending Dec. 31.

We will cooperate with the Safety Council in furnishing reports requested and will make every effort to have a representative of our company attend the meetings sponsored by the Safety Council.

Company Name________________________________

Address______________________________________

Average Number of Employees____________________

Type of Work__________________________________

BWC Policy Number_____________________________

Contact Name_________________________________

Signature____________________________________

Title________________________________________