Form Lb-0393 Tennessee Drug-Free Workplace Premium Credit Program Application
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1
2This form should be completed by the Employer
TENNESSEE DRUG-FREE
Date Application Received
and must be signed by an owner/officer of the
company. After reading and understanding the
WORKPLACE
Rules and Guidelines for Participating
Employers (Chapter 0800-2-12) please answer
PREMIUM CREDIT PROGRAM
all questions that apply. You may also refer to
the Additional Instructions section located on
APPLICATION
the back of this form before submitting this
Departmental Use Only
application.
IMPORTANT: All applications
. Copies will not be
MUST BE COMPLETE, LEGIBLE and SIGNED or they will be RETURNED
accepted. Include the completed original copy of this form plus one photocopy of the completed form, a
copy of PROOF
OF COVERAGE and a self-addressed, stamped #10 envelope addressed to your Workers’ Compensation Insurance Carrier or
. Keep a copy of this form for your records.
Agent of Record for your workers’ compensation policy
Part A-Type of Form (check one):
New Application
Renewal
Termination/Rescission
Changed Ins Carrier
Part B-Applicant Information:
I.
Company Name___________________________________________________________FEIN:____________________________________
Mailing Address__________________________________________________City______________________State & Zip________________
Business Address __________________________________________________City ____________________ State & Zip ______________
Phone #____________________________________________________Fax #_________________________________________________
Email address_____________________________________________________________________________________________________
Nature of Business___________________________________________ Number of Full-time & Part-time Employees_________ /_________
Workers’ Compensation Insurance Carrier_______________________________________________________________________________
Mailing Address__________________________________________________City______________________State & Zip________________
Name of Substance Abuse Program Administrator_________________________________________________________________________
Date written policy statement was provided to all employees____/____/____ Effective date of your program____/_____/____
Drug Testing Program: (Required on all applications.)
II.
Name of Testing Laboratory____________________________________________________ City, State_____________________________
Name of Medical Review Officer (MRO)___________________________________________ City, State_____________________________
Lab Certification: SAMHSA____________CAP-FUDTAP___________Other___________MRO Phone:_____________________________
Education and Employee Assistance Program: (Required on all applications.)
III.
Please provide the date you conducted or plan to conduct an annual minimum two-hour of Workplace Substance Abuse Recognition training
for supervisory personnel. ____/____/____ , ____/____/____
Please provide the date you conducted or plan to conduct an annual minimum one-hour of Workplace Substance Education and Awareness
Program for all your employees. ____/____/____ , ____/____/____
Are employees required to use a designated employee assistance program for substance abuse treatment?
Yes ( ) No ( )
If yes, how many of your employees used it for substance abuse treatment in the past twelve 12 months? _________
If no, do you maintain & post the required list of local employee assistance programs or substance abuse treatment centers? Yes ( ) No ( )
Part C - Renewal Applicants Only:
IV.
Date Previous Program Began ____/____/____ How many employees used it for substance abuse treatment in the past 12 months? ______
Name of Testing Laboratory____________________________________________________ City, State_____________________________
Name of Medical Review Officer (MRO)___________________________________________ City, State_____________________________
Lab Certification: SAMHSA____________CAP-FUDTAP___________Other___________MRO Phone:_____________________________
Number of tests performed in past 12 months for each of the following:
Job Applicants: Positive____ Total____ Routine Fitness for Duty: Positive____ Total____ Post work accident: Positive____ Total____
EAP Follow-up: Positive____ Total____ Reasonable Suspicion:
Positive____ Total____ Random (optional): Positive____ Total____
Part D - Termination / Rescission of Participation by Employer:
V.
Date Previous Program Began____/____/____ How many employees used it for substance abuse treatment in the past 12 months?_______
Number of tests performed in past 12 months for each of the following:
Job Applicants: Positive____ Total____ Routine Fitness for Duty: Positive____ Total____ Post work accident: Positive____ Total____
EAP Follow-up: Positive____ Total____ Reasonable Suspicion:
Positive____ Total____ Random (optional): Positive____ Total____
Reason for Termination / Rescission____________________________________________________________________________________
-0393 (
03/09)
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