Become a MEMIC Agent

Agent Submission Guidelines

Required
Completed ACORD applications must include:

• General Information Application (ACORD 125) 
• Workers' Compensation Application (ACORD 130) 
• Signatures of both the applicant and producer on both applications 
• Answers to all questions on "General Information" section of WC application 
• Complete explanation of all "YES" answers 
• Complete Description of Operations 
• Physical location address(es) 
• Number of employees for each classification 
• Copy of contracts used
• Current NCCI Experience Modification worksheet  
• Loss runs for current and three prior years valued within 6 months of application    
• Premium and payroll history for current and three prior years 

 

Desired  

The following, while not necessarily required for preliminary quote/proposal preparation,
are desirable and may be required before release of final quote:

 

• Most recent audited financial statement 
• Product or operations brochures 
• Copy of Safety Program 
• Copy of Substance Abuse Policy 
• Copy of light duty/return to work programs 
• Copy of Emergency Evacuation Procedures

 

Conditions  

• Coverage cannot be bound until approved by the MEMIC underwriter. 
• After approval, coverage can only be bound after MEMIC receives a deposit
  premium equal to or greater than 25% of the estimated annual premium along
  with the original application signed by both applicant and producer. 
• Premium adjustments (credits or debits) can only be applied by the
  MEMIC underwriter. 
• Coverage will begin no earlier than 24 hours after the postmark on the envelope
  bearing the deposit premium.

 

Submit

MEMIC
Underwriting
underwriting@memic.com
or
P.O. Box 11409
Portland, ME 04104 
or
Fax: 207-791-3335