Needed for Billing
This number is used by the Zurich Care Center to route the transmitted first reports. If known please enter it.
Person submitting order in behalf of the end user customer.
The Company name that the FirstReport Online account will be listed under. This name will be used to set up the FROL account as the official "Employer" name or "Employer Group" name.
What industury or service does your company engage in?
This person will receive the Master UserID for the Comany account in FROL and be the primary contact for setup and support.
Tell us your primary responsibility regarding this order
This is the address that will be used for all official FROL account registration and communication. The physical street address will be needed at setup for all locations to satisfy OSHA recordkeeping requirements.
The primary contact email address for all account registration and setup.
This phone number should be the direct business number for the primary contact for FROL.
Please show us your web site URL so we can learn more about your company
Select an organization description that best describes the customer's need. All choices but "Standard" will receive a consultation call before the order is processed.
Our fees are based in part on the "Average number of Employees" as recognized by OSHA
The estimated number of locations included in the service. This information is to assist in the setup. Location counts do not affect annual pricing but may impact the "One-time" setup fee.
Estimated Number of Users you plan for entering data and running reports. This information is to assist in the setup. User counts do not affect annual pricing but may impact the "One-time" setup fee.
Select all to include in the service contract. Some options may have additional fees. If options are selected you will be contacted before the order is processed to clarify needs and final pricing.
Provide the target date you prefer for account activation.
Please type comments and questions here.