If you would like to request a specific safety service, a copy of our model safety program, or borrow a tape from our safety video training library, please use the following form. Be sure to complete the contact information section at the bottom before submitting the form.

These services and resources are available to KARE insureds only. If you are not currently a KARE policyholder, but are interested in our Workers' Comp Program, please contact an agent in your area or KARE's general office.

(NOTE: Bold type indicates required information, without which the form cannot be processed.)

 PRIVACY STATEMENT: We believe in your right to privacy. We will never trade, sell, rent, lease, barter, or otherwise share any of the following information with a third-party.
SAFETY SERVICES:
Please indicate the specific safety service you would like to request:

Consultant Visit on Program Design and Implementation

Safety Meeting Presentation

Safety Inspection of Your Workplace

Safety Information (please describe below)

Other (please describe below)

If you selected "Safety Information" above, please enter your question or describe the specific subject matter for which you require information:


If you selected "Other" above, please describe the specific service you require:

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MODEL SAFETY PROGRAM:
Do you wish to receive a copy of our Model Safety Program Manual?
Yes   No

If so, please indicate your preferred format:
Printed Format   Disk (Windows only; Microsoft Word 97 or greater)

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SAFETY VIDEO TRAINING LIBRARY:
To borrow a video from our safety video training library, please peruse the list of available titles and indicate the in space below the video number(s) of those in which you are interested. (Note: You do not have to type out the title each video. Simply type the number which appears to the left of the title. Also, if you are requesting multiple videos, please separate video numbers by a comma).

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CONTACT INFORMATION:

First Name:


Last Name:


Company Name:


Position/Job Title:


KARE Policy Number:


Street Address:



City:


State:


Zip Code:


Telephone Number:


Fax Number:


Email:


I prefer to be contacted by:
Email    Telephone

Submit Your Safety Request

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