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:
Email Address:

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