ProActive Works

New Employer Form

Please register to have access to all our work health services

1 - Company Information

Company Name *

Services Required

Work Injuries

Physicals

Both

Main Phone Number *

Fax

Address *

Website

2 - CONTACTS

Primary Contact

Name *

Title *

Phone Number *

Email *

Fax

Secured Fax?

Yes

Secondary Contact

Name

Title

Phone Number

Fax

Secured Fax?

Yes

Reporting Contact

Name

Title

Phone Number

Fax

Secured Fax?

Yes

3 - Billing Information

Address (if different from above)

Billing Contact Name *

Title *

Phone Number *

Email *

Fax *

Secured Fax? *

Yes

Do you want to be billed for first aid? *

Yes

4 - Insurance Information

Insurance Name *

Policy Number *

Address *

Phone Number *

Fax Number *

Effective Start Date *

Effective End Date *

Adjustor Information

Name

Phone Number

Fax

5 - Drug Screening

Do you require post accident urine drug screening? *

Yes

What kind?

5 Panel Test

10 Panel Test

Contact person for drug screening results

Name

Phone Number

6 - Modified Duty

Is modified duty available?

Yes

7 - Username & Password

Create a username and password for Proactive Client Portal

Username

Password

This is the erro

New Employer

Employer Login

Insurance Carrier Login

New Employer Form

1 - Company Information

2 - CONTACTS

Primary Contact

Secondary Contact

Reporting Contact

3 - Billing Information

4 - Insurance Information

Adjustor Information

5 - Drug Screening

Contact person for drug screening results

6 - Modified Duty

7 - Username & Password

866-30HEALTH43258