Company Profile Form

Information entered by:

Date last updated

Company Name

Company billing address

Billing Telephone

Billing Fax

Company Contact/Title

Local Address (if different)

Local Telephone

Local Fax

Local Contact/Title

Consortium

Consortium billing address

Self Insured Texas Worker's Comp Other

Will we handle your work injuries?

Yes No

Name of Insurance Company

Address

Phone

Contact

Do you have/accept modified duty?

Yes No

Drug Screens required all injuries?

Yes No

Name of Person to receive results:

To be notified by:

Fax Phone Email

Chain of Custody

Will bring with them We have in our files Other

Notes re: Chain of Custody