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Name of Person Completing Form
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First
Last
Firm Name (if applicable)
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Phone Number
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Email
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Preferred Method of Contact
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Text
Email
Phone
Name of Person Equipment is For
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First
Last
Claim # (if applicable)
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State Fund
Self Insured
Delivery Address
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Line 1
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City
State
Zip Code
Country
Phone Number (for delivery purposes only)
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SIMPLIFY THE PROCESS: UPLOAD an Ergo/AT eval report here and skip the sections below.
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Max file size: 20MB
What type of equipment are you requesting? (click all that apply)
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Computer/Laptop
Wireless Keyboard & Mouse
Monitor Stand/Laptop Riser
Laptop Rolling Backpack
Computer Monitor
Microsoft Suite Software
Other (please specify in comment section)
If a laptop is requested, what is the intended use? (click all that apply)
*
General School or Office
Use of Voice Activation Software
Accounting (10-key Keyboard)
CAD or Engineering
Other (please specify in comment section)
Ergonomic Equipment
*
Ergonomic Chair
Sit/Stand Desk
Laptop Riser
Ergonomic Keyboard (Kinesis, Logitech, etc)
Ergonomic Mouse (upright, rollerball, trackpad)
Footrest
Voice Activated Software (Dragon)
Headset or Microphone
Anti Fatigue Mat
Other(Please specify in comment section)
Other Equipment Needed/ Additional Information or Requests
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If you have a specific model or item that you are looking for, indicate that here.
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Home
L&I/VRC Portal
Computers & Technology
Ergonomics
Tech & Ergo Quote
Instant Quote
OPTION 2
RESOURCES
CONTACT
