Submission Guidelines

Required

• Workers’ Compensation Application (ACORD 130)
   Please complete:
  • Number of employees for each classification
  • Answers to all questions on “General Information” section of application
  • Explanation of all “YES” answers
  • Description of Operations
  • Physical location address(es)
• 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

Conditions

• Coverage cannot be bound until approved by the MEMIC underwriter
• After approval, coverage can only be bound after MEMIC receives a deposit premium or Comp As You Go intent form with the original application signed by both applicant and producer
• Coverage will begin no earlier than 24 hours after the postmark on the envelope bearing the deposit premium or Comp As You Go intent form

Submit

Please send submissions via mail, email or fax:

MEMIC Underwriting
PO Box 11409
Portland, ME 04104
submissions@memic.com
Fax: 207-791-3335