Get Application For Certification Or Annual - State Board Of Workers ...

This guide provides a clear and structured approach to filling out the Application for Certification or Annual Recertification of the Drug-Free Workplace Premium Credit Program online. Whether you are applying for the first time or renewing your certification, this guide will walk you through each section of the application form.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by filling out the required fields in Section A, which include the Coordinator’s Name, Email, Company Name, Federal Employer Identification Number (FEIN), Phone Number, Physical Address, City, State, ZIP Code, County, and Mailing Address if it differs from the physical address.
3. In Section B, indicate how many years your company has been certified as a drug-free workplace employer. Select either ‘This will be our first year’ or ‘This is our 2nd or subsequent year.’
4. Complete Section C by selecting how your company is insured for workers' compensation. Choose an option from Insurance Policy, Private Self-Insured, or Group Fund Self-Insured.
5. Review Section D, which contains a checklist of necessary policies and statements you need to confirm for compliance with the drug-free workplace program. Ensure you have the required information and check each item as applicable.
6. Proceed to fill in the name and address of the confirming laboratory in Section E. Include the certification of the laboratory by selecting Health and Human Services (HHS), College of American Pathologists (CAP), or both.
7. Finalize the form by printing it out for your review. Ensure all sections are completed, sign the document, and have it notarized as required.
8. Once notarized, send the application along with the $35.00 certification fee to the address provided. Keep a copy of your submitted application for your records.

Complete your application online now to ensure your certification for the Drug-Free Workplace Premium Credit Program.