| Instructions: |
| This form will populate an email that you can send to the Specialists or Consultants you selected.
Please check the appropriate boxes and fill in the text boxes with your information. |
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| Part A: |
Fill this section out only if you want to participate in the Workplace Safety and Loss Prevention Incentive Program under ICR 60.
You may check the boxes for more than one program, if applicable. |
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| Part B: |
Check this box only if you received a letter from the New York State
Compensation Insurance Rating Board (CIRB) that says you must participate in the Mandatory Workplace Safety and Loss Prevention Program under ICR 59.
If you received this letter, you may not take part in the Incentive Program, so you may not fill out Part A. |
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| Part C: |
Everyone should fill out this section. |
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| I am inquiring as to your availability and pricing for Workplace Safety and Loss Prevention services. |
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| Part A: |
| My business has the following Workplace Safety and Loss Prevention Incentive Program(s): |
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| ICR 60 Safety Program |
| ICR 60 Drug and Alcohol Prevention Program |
| ICR 60 Return to Work Program |
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| My business has already put this program in place and just needs an evaluation. |
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| My business needs assistance putting this program in place and needs an evaluation. |
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| Part B: |
| I must comply with ICR 59, the Mandatory Workplace Safety and Loss Prevention Program, and my business needs a consultation and evaluation. |
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| Part C: |
| My business name and industry type is: |
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| The business' main office location is: |
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| Please reply to this email address or contact me at: |
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