Request For Services
Request For Services Form. This is a Missouri form and can be use in Workers Comp.
Tags: Request For Services, LSWSP-6, Missouri Workers Comp,
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF LABOR STANDARDS MISSOURI WORKERS’ SAFETY PROGRAM REQUEST FOR SERVICES Company Name ________________________________________________________________________________________ Street Address _________________________________________________________________________________________ City _____________________________________________ State ___________________ ZIP ________________________ Type of Business _______________________________________________________________________________________ Contact Person _________________________________________________________________________________________ Phone # _________________________________________ Fax # _______________________________________________ Insurance Carrier ______________________________________________________________________________________ Self-Insured Employer or Group Trust __________________________________________________________________ Website __________________________________________ E-mail Address ______________________________________ NOTE: You may request services from both your insurance carrier and the Missouri Workers’ Safety Program (MWSP). 1. I am interested in receiving the following free services from the Missouri Workers’ Safety Program: Safety Consultation Visit, including: Advice on workers’ compensation safety and health issues, including discussion of experience modification, classifications, rates, reserves, and employer choice of physician A walk-through safety review of my facility Advice on how to establish a basic safety program A review of my current safety program A copy of the MWSP’s registry of certified safety consultants and engineers Information on the Missouri Safety and Health Consultation Service (OSHA Outreach Program) 2. I am interested in receiving the following services from my workers’ compensation insurance carrier (Missouri law RSMo 287.123 requires all insurance carriers writing workers’ compensation in the state of Missouri to submit a written outline of their comprehensive safety management and engineering program for certification): Assistance in developing a comprehensive safety and health program Assistance in identifying health hazard exposures Assistance in conducting accident investigations A review of existing written safety programs A safety and health review, including an on-site visit Assistance in establishing a return-to-work program(s): Hazard Communication Lock-out/Tagout Personal Protective Equipment Hearing Conservation Blood borne Pathogen Forklifts & Industrial Trucks Confined Space Entry Fall Protection Respiratory Protection Fire & Emergency Action Plans Other Mail or fax this completed request form to: Missouri Workers’ Safety Program P.O. Box 449 Jefferson City, MO 65102-0449 Phone: 573-751-3403 Fax: 573-751-3721 E-mail: email@example.com Further information is available on our Internet home page: www.labor.mo.gov/SAFE LSWSP-6 (07-10) AI American LegalNet, Inc. www.FormsWorkFlow.com