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Become a MEMIC Agent

Agent Submission Guidelines

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 



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



  • 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.



P.O. Box 11409
Portland, ME 04104 
Fax: 207-791-3335