Inquiry Form

How Do I Determine If My Company Qualifies?

Please let me know whether my company might qualify for membership in a Lovell Safety Group, based on the following information. I understand I may have to supply additional data, and that membership is contingent on the accuracy of the details I am providing herewith and in the future.

 
Name of Company:
 
Street Address:
 
City • State • Zip:
 
General Industry:

If your industry is not listed above, we regret to inform you that your company is NOT eligible for any of our Safety Groups.
 
Number of Employees:
 
Your Workers’ Compensation Policy Renewal Date (MM/DD/YY/):
  / /
 
Current Workers’ Compensation Insurance Carrier:
 
Your Name:
 
Title:
 
Telephone:
 
Email Address:
 
 

Watch Our Presentation on Workers' Compensation