SAFETY COUNCIL:

MEMBERSHIP APPLICATION

BWC co-sponsors safety councils to provide Ohio employers with access to occupational safety and health, workers’ compensation and risk management education, networking, and resource sharing.

In completing this enrollment form, the employer makes a commitment to send representatives to monthly safety council meetings.

Fill in the form below and select Print or save as PDF. Your answers are placed on the official enrollment form. In the print window, choose your printer, or choose Save as PDF as the destination to keep a copy. Sign the printed form by hand.

Employer

Employer name (required)

Physical address (required)

City (required)

State (required)

ZIP (required)

Phone number (required)

E-mail address (required)

BWC policy number (required)

Authorized representative

Printed name (required)

Title (required)

Signature: sign the printed form by hand.

Blank application to fill out by hand (PDF) (opens in a new window)