Fillable Certified Workplace Medical Plan Consent to Participate Return (National American Insurance Company)

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Certified Workplace Medical Plan Consent to Participate Return (National American Insurance Company)

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Country of origin: US
File type: PDF

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Certified Workplace Medical Plan
Consent to Participate
Return to cwmpenrollment@naico.com
or
FAX to 405-240-5591
Employer Name:
Address:
Phone: Fax: ______
Workers’ Compensation Contact:
Number of Employees:
Hours of Operation: ______
Type of Business:
Effective Date of Plan:
PLEASE FILL OUT COMPLETELY
Certified Workplace Medical Plan (Workers Compensation Act Title 85A O.S. sec 56)
This Company is participating in CorVel’s CWMP
Review your company’s procedure for reporting an injury: Carrier/CorVel CWMP Injury Notification
should take place within 24-48 hours of the date of injury
Post the CorVel workplace posters in appropriate locations throughout the company property (if
applicable).
The Payor / Insurance Company: National American Insurance Company
Broker:
Automatically renewed one year from the effective date of this Agreement. This Agreement will be
automatically renewed for consecutive 12-month periods, or until the employer’s policy with the payor /
Insurance company terminates. This agreement may be terminated without cause with a thirty (30) day
written notice by either party.
______________________________________ _________________________
Company Contact name, please print Date
_________________________________________
Company Contact Signature
_________________________________________ __________________________
CorVel Corporation
Date
CWMP 2015
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Certified Workplace Medical Plan Consent to Participate Return (National American Insurance Company)

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Completed 29 July 2021

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