Lovell Safety Management Co., LLC

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:

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