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Submissions

Submissions Application

Please complete the form below including all required information.

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Acord 130 Loss runs



Premium History Mod Worksheet


SUBMISSION REQUIREMENTS

  • Workers’ Compensation Application (Acord 130)
  • 3 Years of Loss Runs (Valid Within 60 Days)

SUBMISSION INSTRUCTIONS

Please submit the requirements outlined above using the form to the left. Once your submission has been received and reviewed, a representative will be in contact with you within one business day.