Audit Assistance - Reliable Premium Management : Reliable Premium Management

Please select the following option that applies to you. *

First Time User

Name* *

First

Last

Phone* *

Email* *

Relationship to the account?* *

Policyholder
Accountant
Agent

Is the policy in danger of cancellation?* *

Yes
No

Best time to contact you?* *

Best method of contact?* *

Phone
Email

Audit Request by Accountant

Name* *

First

Last

I certify that I am the Accountant hired on behalf of the company listed below and that I have the authority to enter into this agreement on the Company's behalf. I authorize Reliable Premium Management, Inc (RPM) to conduct a review of the company's workers' compensation audit.

Company Name* *

FEIN* *

Business Structure* *

LLC
Corp
Sole Prop
Partnership

Address* *

Address Line 1

Address Line 2

City

State

Zip Code

Authorized Company Contacts:

I hereby authorize the following individual(s) to communicate with RPM regarding they company's payroll and workers’ compensation matters. These individual(s) have the authority to discuss the classification of employees and online access to payroll reports with the payroll vendor. I understand that the following individual(s) will be notified via email prior to any charges being withdrawn from my account.

Name

Phone

Email

Name

Phone

Email

Payroll Company

I authorize RPM access to our payroll reports through our payroll provider listed below.

Payroll Frequency* *

Weekly
Bi-Weekly
Semi-Monthly

Name of Payroll Company* *

Payroll Client ID

Agent/Broker Information

Servicing Insurance Agent/Broker Name

Agency Name

Phone

Email

Policy Information

Carrier* *

Policy Number* *

Policy Start Date* *

Policy End Date* *

Audit Review Assistance Options* *

Traditional Audit Review - $79/hour Receive an explanation within 14-21 business days after all documentation is received
Rush Audit Review - $129/hour Receive an explanation within 7-14 business days after all documentation is received

RPM Payment Authorization Agreement

Payment Options* *

ACH Debit
Credit Card

Credit Card

I authorize Reliable Premium Management to charge the credit card indicated on this form. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; provided the transactions correspond to the terms indicated in this authorization form. A 4.25% Convenience Fee applies to credit card transactions.

Account Type* *

Visa
MasterCard
AMEX
Discover

Cardholder Name* *

Billing Address* *

Address Line 1

Address Line 2

City

State

Zip Code

Card Number* *

Expiration Date* *

CVC* *

ACH Debit

*Please send us a voided check. This Agreement governs ACH transactions initiated by Reliable Premium Management to debit or credit the Company indicated below. Both parties agree that this Agreement in conjunction with any of the designated methods constitutes authorization to debit Company’s business bank account, and Company agrees not to dispute any debits with its bank provided the transaction(s) correspond to the terms indicated in this Agreement. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) Company understands that Reliable Premium Management may at its discretion attempt to process the charge again up to 3 times within 30 days, and agrees to an additional $40 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. Company has certified that the business bank account below is enabled for ACH transactions, and agrees to reimburse Reliable Premium Management for all penalties and fees incurred as a result of Company’s bank rejecting ACH debits or credits as a result of the account not being properly configured for ACH transactions

Company Name on Account* *

Bank Name* *

Bank Routing Number* *

Bank Account Number* *

Audit Request by Policyholder

Name* *

First

Last

I certify that I am the owner of the company listed below and that I have the authority to enter into this agreement on the Company's behalf. I authorize Reliable Premium Management, Inc (RPM) to conduct a review of my workers' compensation audit.

Company Name* *

FEIN* *

Business Structure* *

LLC
Corp
Sole Prop
Partnership

Address* *

Address Line 1

Address Line 2

City

State

Zip Code

Authorized Company Contacts

I hereby authorize the following individual(s) to communicate with RPM regarding they company's payroll and workers’ compensation matters. These individual(s) have the authority to discuss the classification of employees and online access to payroll reports with the payroll vendor. I understand that the following individual(s) will be notified via email prior to any charges being withdrawn from my account.

Name

Email

Phone

Name

Email

Phone

Payroll Company

I authorize RPM access to our payroll reports through our payroll provider listed below.

Payroll Frequency* *

Weekly
Bi-Weekly
Semi-Monthly

Name of Payroll Company* *

Payroll Client ID

Agent/Broker Information

Servicing Insurance Agent/Broker Name

Agency Name

Phone

Email

Policy Information

Carrier

Policy Number

Policy Start Date

Policy End Date

Audit Review Assistance Options* *

Traditional Audit Review - $79/hour Receive an explanation within 14-21 business days after all documentation is received
Rush Audit Review - $129/hour Receive an explanation within 7-14 business days after all documentation is received

RPM Payment Authorization Agreement

Payment Options* *

ACH Debit
Credit Card

Credit Card

Credit Card: I authorize Reliable Premium Management to charge the credit card indicated on this form. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; provided the transactions correspond to the terms indicated in this authorization form. A 4.25% Convenience Fee applies to credit card transactions.

Account Type* *

Visa
MasterCard
AMEX
Discover

Cardholder Name* *

Billing Address* *

Address Line 1

Address Line 2

City

State

Zip Code

Card Number* *

Expiration Date* *

CVC* *

ACH Debit

ACH: This Agreement governs ACH transactions initiated by Reliable Premium Management to debit or credit the Company indicated below. Both parties agree that this Agreement in conjunction with any of the designated methods constitutes authorization to debit Company’s business bank account, and Company agrees not to dispute any debits with its bank provided the transaction(s) correspond to the terms indicated in this Agreement. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) Company understands that Reliable Premium Management may at its discretion attempt to process the charge again up to 3 times within 30 days, and agrees to an additional $40 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. Company has certified that the business bank account below is enabled for ACH transactions, and agrees to reimburse Reliable Premium Management for all penalties and fees incurred as a result of Company’s bank rejecting ACH debits or credits as a result of the account not being properly configured for ACH transactions.

Company Name on Account* *

Bank Name* *

Bank Routing Number* *

Bank Account Number* *

Audit Request by Agent

Full Name* *

I certify that I am the Agent of record on behalf of the company listed below and that I have the authority to enter into this agreement on the Company's behalf. I authorize Reliable Premium Management, Inc (RPM) to conduct a review of the company's workers' compensation audit.

Company Name* *

FEIN* *

Business Structure* *

LLC
Corp
Sole Prop
Partnership

Address* *

Address Line 1

Address Line 2

City

State

Zip Code

Authorized Company Contacts:

I hereby authorize the following individual(s) to communicate with RPM regarding they company's payroll and workers’ compensation matters. These individual(s) have the authority to discuss the classification of employees and online access to payroll reports with the payroll vendor. I understand that the following individual(s) will be notified via email prior to any charges being withdrawn from my account.

Name

Email

Phone

Name

Email

Phone

Payroll Company

I authorize RPM access to our payroll reports through our payroll provider listed below

Payroll Frequency* *

Weekly
Bi-Weekly
Semi-Monthly

Name of Payroll Company* *

Payroll Client ID

Agent/Broker Information

Servicing Insurance Agent/Broker Name

Agency Name

Phone

Email

Policy Information

Carrier* *

Policy Number* *

Policy Start Date* *

Policy End Date* *

Audit Review Assistance Options* *

Traditional Audit Review - $79/hour Receive an explanation within 14-21 business days after all documentation is received
Rush Audit Review - $129/hour Receive an explanation within 7-14 business days after all documentation is received

RPM Payment Authorization Agreement

Payment Options* *

ACH Debit
Credit Card

ACH Debit

This Agreement governs ACH transactions initiated by Reliable Premium Management to debit or credit the Company indicated below. Both parties agree that this Agreement in conjunction with any of the designated methods constitutes authorization to debit Company’s business bank account, and Company agrees not to dispute any debits with its bank provided the transaction(s) correspond to the terms indicated in this Agreement. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) Company understands that Reliable Premium Management may at its discretion attempt to process the charge again up to 3 times within 30 days, and agrees to an additional $40 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. Company has certified that the business bank account below is enabled for ACH transactions, and agrees to reimburse Reliable Premium Management for all penalties and fees incurred as a result of Company’s bank rejecting ACH debits or credits as a result of the account not being properly configured for ACH transactions.

Company Name on Account* *

Bank Name* *

Bank Routing Number* *

Bank Account Number* *

Credit Card

I authorize Reliable Premium Management to charge the credit card indicated on this form. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; provided the transactions correspond to the terms indicated in this authorization form. A 4.25% Convenience Fee applies to credit card transactions.

Account Type* *

Visa
MasterCard
AMEX
Discover

Cardholder Name* *

Billing Address:* *

Address Line 1

Address Line 2

City

State

Zip Code

Card Number* *

Expiration Date* *

CVC* *