ENROLL ONLINE

Online Enrollment Form

Southern Buckeye Safety Council

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, BWC’s Division of Safety & Hygiene and the Southern Buckeye Safety Council co-sponsor this service.

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.

If you have questions or need help while completing this form please contact

* Indicates required field

Enrollment Date: *

Employer Name: *

Address (Line 1) *

Address (Line 2) *

City *

State *

Zip Code *

County *

Phone Number *

Email *

Average number of employees: *

Type of work (i.e.: Contruction, Food Service, School, Social Services, etc.) *

BWC Policy Number (Enter "0" if unknown) *

Name *

First

Last

Title: *

How did you hear about us? *

If you were referred, who referred you? *

Signature (Retype your name) *

Signature Date: *

Submit

Semi-Annual Report

DOWNLOAD SEMI-ANNUAL REPORT FORM

HOME PAGE