(order will be filled and delivered in 4-7 business days)
 

Date:	Street Address:
5/16/2012
Agency Contact:	City:
Agency Number:	State/Zip Code:
	Select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming /
Agency Name:	Phone:
	E-mail:

General
Quantity	Supply			Description
	E-11	PDF		Courtesy Reply Envelopes
	PA-50	PDF		Employer’s Audit Guide
	CC-1636	PDF		Fraud Poster
	CC-12583			Marketing Folders (Empty)
	CC_11141			3 Ring Binder Folder (Empty)
	U-67	PDF		Notice to All Employees Poster
	E-17	PDF		Payment Envelopes (Billing)
				State Required Posting Notices You can obtain most posting notices at this Web site: http://www.workerscompensation.com/ If ordering, please specify state --->
Brochures
Quantity	Supply			Description
	CC-1809-06	PDF		A.M. Best Brochure
	CC_12589	PDF		Financial Report – 2006
	CC-1686	PDF		Complete Hernia Program (MI only)
	CC_3435	PDF		Loss Prevention Toolbox Flyer
	CC_13148	PDF		Policyholder Guide
	CC_3109	PDF		Policyholder Overview
	BD-3294	PDF		Claims Flyer
	BD-12818	PDF		Class Codes Flyer (MI)
	BD-12052	PDF		Early Reporting Flyer
	AR_12581	PDF		Accident Fund Highlight Flyer for Policyholders
	CL-12719	PDF		Return to Work Flyer
Groups Program Materials
Quantity	Supply			Description
	CC_12350_MI	PDF		Groups Program for Agents (MI)
	BD_12620_IA	PDF		Groups Program for Agents (IA)
	BD_12620_IN	PDF		Groups Program for Agents (IN)
	BD_12620_IL	PDF		Groups Program for Agents (IL)
	CC_12353_MI/IL/IN	PDF		Groups Program for Business Owners (MI/IL/IN)
	CC_12353_IA			Groups Program for Business Owners (IA)
	BD_11713	PDF		Small Biz Reward Program (WI)
	CC_12875	PDF		Groups Program for Chamber Members
	AR-12899 Agent	PDF		Groups Highlight Flyer for Agents
	AR-12899 Policyholder	PDF		Groups Highlight Flyer for Policyholders
	KIT_12973 **Select State** Iowa Indiana Illinois Michigan			Group Marketing Kits for Business Owners
Loss Prevention Materials
Quantity	Supply			Description
	BD_13069	PDF		2008 WorkSafe Calendars
	LP_11944	PDF		General Safety Manual
		PDF		General Safety Manual Quiz Answer Key
	LP_12459	PDF		Back Injury Manual
	CC_12523	PDF		Back Injury Poster
	LP_12460	PDF		Ergonomics Manual
	CC_12520	PDF		Ergonomics Poster
	LP_12461	PDF		Personal Protective Equipment Manual
	CC_12522	PDF		Personal Protective Equipment Poster
	LP_12462	PDF		Slip and Fall Prevention Manual
	CC_12521	PDF		Slip and Fall Prevention Poster
	**Select 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter (select quarter for the current year)			WorksSafe Update Newsletter Click here to access PDF copies
	ADM1100	PDF		Building a Safety Program for Your Organization
	ADM1101			Safety and the Supervisor
	ADM1102	PDF		How to Lower Your Workers Compensation Costs
	EME 1100	PDF		Knowledge is Workplace Violence Prevention
	EMP 1100	PDF		Establishing an Effective Return-to-Work Program
South Carolina Forms
Quantity	Supply			Description
	CL_11253	PDF		Second Injury Fund Participation Agreement
	BD_11285	PDF		Post-Offer-of-Employment Medical Injury
Other – Please Describe
				For questions regarding your order, please contact Tammie Coleman at (517) 367-1830.