Drug-Free Discount - Annual Renewal
This program offers approved employers a ten percent (10%) discount off their base rate for the implementation of a drug free workplace program.

Please submit this application electronically ONLY IF YOU HAVE NO POLICY CHANGES.

Email address *
9 Digit Employer Number (Workers' Compensation Number) *
Your answer
Employer/Business Name *
Your answer
Office/Owner Name *
Your answer
Office/Owner Phone Number: *
Your answer
Drug-Free Workplace Coordinator Name *
Your answer
Coordinator's Email *
Your answer
Coordinator's Phone Number *
Your answer
Employer Address (include city, state and zip code) *
Your answer
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