HFC SAFETY COUNCIL

NEW ENROLLMENT FORM

In an effort to reduce the number of workplace accidents and to share resources and information on accident prevention, risk management and workers’ compensation in Ohio, the BWC’s Division of Safety & Hygiene and your local safety council co-sponsor this program.

In signing this enrollment form, the employer makes a commitment to send representatives to the majority of safety council meetings and to submit

semi-annual reports by the deadline dates.

Company Name

Address

City County Zip

E-Mail Address

Phone Fax

Average Number of Employees

Type of Work

BWC Policy Number

Enrollment Year

Name

Signature

Title

TO BE COMPLETED BY THE SAFETY COUNCIL

Safety Council Account Number

(Must be completed before forwarding to DSH)

_______________________________ / ____ ____ / ____ ____ / ____ ____

HFC Safety Council

Highland County Chamber of Commerce

1575 N. High Street, Suite 400

Hillsboro, OH 45133

(937) 393-1111 (phone) (937) 393-9604 (fax)