WC Approval Request

WORKER'S COMPENSATION APPROVAL REQUEST
Recruiting Firm Name *
Recruiter Name *
Recruiter E-mail *
Physical Work Location (i.e. office, hospital, warehouse, outpatient facility, nursing home) *
If in healthcare industry, is there any direct patient contact? *

YES NO
Job Title *
Pay Rate *
State *
Company Name that the Employee will be working for *

Company Address that the Employee will be working *