4Safety Excellence Program (4SEP) – Online Enrollment Form Registrations are open for 2020 Email Choose the applicable option: * My organization is COR™ or ISO Certified Organization. My organization is COR™ or ISO in progress. My organization belongs to the industrial/retail/services sector. My organization is a large corporation with 500+ staff and/or multiple locations. Registration is for: * One WSIB Firm Number Multiple account and firm numbers. Please select the participation option that you are interested in: * COR/ISO In Progress Group Offering - $1000.00+HST per WSIB firm account up to $1,000,000 in premium Mixed Group Offering - $1000.00+HST per WSIB firm account up to $1,000,000 in premium Industry Group Offering - $1000.00+HST per WSIB firm account up to $1,000,000 in premium Custom Group Offering $1000.00+HST per WSIB firm account + 0.1% of total premium over $1,000,000 Dedicated 1:1 Offering - Price to be mutually determined WSIB Firm Number * WSIB Account Number * WSIB Annual Premium For 2019 (to help us calculate the approximate rebate amount and suggest the number of topics) Full name of primary contact for your company for the WSIB Excellence program: Company's Legal Name * Company Address * City * Postal Code * Email Address * Phone Number Cell Number How did you hear about us? MOL Website 4S Info Bulletin 4S Newsletter IHSA Third-party websites Colleague Google search LinkedIn Twitter Facebook Flyers Brochures Marketing phone call Other source WSIB Information Session Health & Safety Excellence Seminar ECAO Membership Seminar Please note that your response to this question helps us best serve you with timely information and updates on occupational health and safety enrollment terms I, the undersigned, agree to enroll for the 4Safety Excellence Program. I consent to receive email communication & newsletter updates from the 4S team for the same. Print Name * Date *