MVSAM Membership Registration/Application

Companies that fall under the following rate codes of the workers compensation board of Manitoba may already be members in which case the company just needs to complete the registration form at no cost.

  • 60402 auto sales and repair
  • 60404 auto body shops
  • 60503 heavy industrial equipment sales and service

Please enter your company name and verify or correct the information.

We welcome associate members too. Please fill out the application form and a representative will follow up with registration cost and explanation of benefits before proceeding.

Company Information

Company Name:
Address:
City:
Province:
Postal Code:
Number of Employees:

Contact Information

Person completing this form

Name:
Position:
Email Address:
Office Phone Number:
Mobile Phone Number:
 

Main Contact (Administrator)

Name:
Position:
Email Address:
Office Phone Number:
Mobile Phone Number:
 

Safety Contact In Your Company

Name:
Position:
Email Address:
Office Phone Number:
Mobile Phone Number:
 
Please check the boxes that apply to your company:
 
Trade Affiliation:
Group Affiliation: 
 
WCB Number:
Are you a member of another safety association? If yes, please specify:
SAFE Work Certified 
Is your company currently or interested in pursuing SAFE Work Certified (SWC) Safety & Health Certification?:

  
If yes, please indicate SWC Safety Association: 

Authorization

  • I am authorized to register this company with MVSAM
  • That I understand that MVSAM will keep our company information private and not sell or disclose to a third party.
  • Under Canadian Privacy Legislation requirements I authorize MVSAM and its agents to communicate with this company with the understanding that I can opt out at any time by selecting the unsubscribe option at which time communication will cease.