ISNetworld Customer Intake Form

SAFETY DEFINED, LLC
ISNetworld Account Setup Intake Form

Thank you for choosing Safety Defined, LLC to assist with your ISNetworld account setup. Please complete the form below with the necessary details to get started.
Company Name*
Legal Business Name if different
Year Started*
Employer Identification Number EIN*
DUNS Number
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Website if applicable
Primary Contact Name*
Title*
Email Address*
example@example.com
Phone Number*
Secondary Contact Name if applicable
Secondary Contact Email
example@example.com
Secondary Contact Phone Number
3. Business & Operational Details Type of Business (LLC, Corporation, Sole Proprietor, etc:
Type of Business LLC Corporation Sole Proprietor etc*
Primary IndustryTrade*
Services Provided
NAICS Code if known
SIC Code if known
StatesRegions of Operation
Federal State or Local Certifications if applicable
4. Insurance Information Insurance Provider Name:
Insurance Provider Name*
Insurnace Provider Contact*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Insurance Policy Number
Coverage Types Limits
Insurance Expiration Dates

MonthDayYear
Date
Certificates of Insurance Uploads

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Do you have a written safety program?*

YesNo
Written Safety Program

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Does your company have a designated safety officer?*

YesNo
If yes, Safety Officer Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
OSHA Compliance History Any past violations or citations
Total Recordable Incident Rate TRIR for past 3 years
Experience Modification Rate EMR for past 3 years
Safety Training Programs Documentation*

YesNo
Safety Training Rosters

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6. Workforce & Hiring Practices
Total Number of Employees*
Subcontractors Used?*

YesNo
Pre-Employment Drug & Alcohol Testing Policy?*

YesNo
If you have any questions, feel free to contact us at (412) 412-0181 or Levi@safetydefined.com
We look forward to helping you streamline your compliance needs!
Additional Documentation

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Should be Empty:

SAFETY DEFINED, LLC