For appointed agents
Workers' compensation submission guidelines
Review the information needed for a complete workers’ compensation submission and send your application to MEMIC for underwriting review.
What to include
Required submission information
Include the applicable information below to help avoid delays in underwriting review.
Workers’ compensation application
Submit a completed Workers’ Compensation Application, ACORD 130.
Please include:
- Number of employees for each classification
- Answers to all questions in the General Information section
- An explanation for every “Yes” answer
- Description of operations
- Physical location address for each location
- Current NCCI experience modification worksheet
- Loss runs for the current year and three prior years, valued within six months of the application
- Premium and payroll history for the current year and three prior years
Before binding coverage
Submission conditions and delivery
- Coverage cannot be bound until it is approved by a MEMIC underwriter.
- After approval, coverage may be bound only after MEMIC receives a deposit premium or Comp As You Go intent form with the original application signed by both the applicant and producer.
- Coverage will begin no earlier than 24 hours after the postmark on the envelope containing the deposit premium or Comp As You Go intent form.
Send submissions by email, mail, or fax.
- Email
[email protected] - Mail
MEMIC Underwriting
PO Box 11409
Portland, ME 04104 - Fax
207-791-3335
Contact the MEMIC Underwriting Department at 1-800-660-1306.