Company Information Company Name Number of Employees Address PO Box City State Zip Contact Name Contact Email Company Phone Company Fax Personnel Able to Authorize Visits Authorized Personnel 1 - Name Authorized Personnel 1 - Phone Authorized Personnel 2 - Name Authorized Personnel 2 - Phone Authorized Personnel 3 - Name Authorized Personnel 3 - Phone After Hours Contact After Hours Contact - Name After Hours Contact - Phone Accounts Payable Contact Accounts Payable Name Accounts Payable Phone Accounts Payable Fax Accounts Payable Email Worker's Comp Subscribers Are you a subscriber to Texas worker's compensation insurance? Yes No Carrier Name Address PO Box City State Zip Phone Fax Special Instructions Services Needed Services Needed On The Job Injury Pre-employment Services Other Require a drug screen with injury? Yes No Standard Drug Screens Standard 10-Panel Standard 5-Panel DOT Drug Screen Instant Drug Screens Instant 10-Panel Instant 5-Panel Collection Only - Lab Name Other Services Breath Alcohol Test DOT Physical Basic Occupational Physical Other If other, please explain Results Reporting Drug screen results only Name Fax Email Please specify your preference for receiving physicals, work status reports, etc By Fax By regular mail Fax Mail