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Authorization For Premium Remittal

Instructions

An RPM Authorization For Premium Remittal form must be completed, signed, and submitted in order for RPM to commence services on behalf of a policy. The policy will need to be bound according to the instructions listed in the form in order for RPM to facilitate Pay-As-You-Go services.

Find your Insurance Carrier below to either download or submit online.

Click or drag a file to this area to upload.

Authorization For Premium Remittal FORMS LISTED BY CARRIER

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If you would like to inquire about a carrier not listed below, please CLICK HERE.

 

Carrier Name PDF DownloadOnline FormBIND Instructions

Acadia Insurance

PDF FormOnline FormBIND as ClosePay through SmartPay/RPM
Acuity InsurancePDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
AF GroupPDF FormOnline FormBIND as AccuPremium
AlaCOMPPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
ALMA-American Longshore Mutual AssociationPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Amerisure InsurancePDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
AmTrust North AmericaPDF FormOnline FormBIND as PAYO through Reliable Premium Management
AmWINS SpecialtyPDF FormOnline FormBIND as PayGo through RPM
Arch InsurancePDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Arrowhead-EverestPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Ascendant Insurance SolutionsPDF FormOnline FormBIND as PayGo through Reliable Premium Management
Atlas GeneralPDF FormOnline FormBIND as Atlas GoPay

Beacon Aviation Insurance

Services

PDF FormOnline FormBIND as PAYO through Reliable Premium Management
Beacon Mutual InsurancePDF FormOnline FormBIND as Beacon Pay-As-You-Go
Benchmark-American LibertyPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Benchmark-BenchmarkPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Benchmark-CompStarPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Benchmark-DiamondPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Berkley Mid-Atlantic GroupPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Berkley NetPDF FormOnline FormBIND as PayGo through SmartPay/RPM
BHHC (Berkshire Hathaway Homestate Companies)PDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Builders Insurance GroupPDF FormOnline FormBIND as PayGo through RPM
Builders Mutual Insurance CompanyPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)

CA State Compensation Insurance Fund

PDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Chesapeake Employers InsurancePDF FormOnline FormBIND as PayGo through SmartPay/RPM
Clear Spring – CCMSIPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Clear Spring – ParagonPDF FormOnline FormBIND as PayGo through RPM
Clear Spring – TangramPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
C.N.A. InsurancePDF FormOnline FormBIND as C.N.A. Payroll Reporting
CimarronPDF FormOnline FormBIND as PayGo through RPM
Crum & ForsterPDF FormOnline FormBIND as PayGo through SmartPay/RPM

Employers

PDF FormOnline FormBIND as PrecisePay
Erie InsurancePDF FormOnline FormBIND as Erie PaySense
Everest NationalPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)

Farmers Insurance

PDF FormOnline FormBIND as Farmers Real-Time Billing
FCBI FundPDF FormOnline FormBIND as PayGo through RPM
FCCIPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
FFVAPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
FHMPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
First Benefits Insurance MutualPDF FormOnline FormBIND as PayGo through RPM
Frank Crum PDF FormOnline FormBIND as PayGo through RPM
FUBAPDF FormOnline FormBIND as PayGo through RPM

Grange Insurance

PDF FormOnline FormBIND as Pay As You Go
GUARD Insurance GroupPDF FormOnline FormBIND as GRIP-Reliable Premium Management

Hanover Insurance Company

PDF FormOnline FormBIND as Hanover EZPay
Hawaii Employer’s Mutual Insurance CompanyPDF FormOnline FormBIND as AePay

ICW Group

PDF FormOnline FormBIND as EZ Report through RPM

Key Risk Insurance

PDF FormOnline FormBIND as PayGo through RPM

Lackawanna Casualty Company

PDF FormOnline FormBIND as Monthly Self-Reporter (Premiums collected per pay period)
Liberty MutualPDF FormOnline FormBIND as Monthly Self-Reporter (Premiums collected per pay period)
LUBA Workers’ CompPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)

Markel Insurance

PDF FormOnline FormBIND as Markel PayGo
MCIM (Michigan Commercial Insurance Mutual)PDF FormOnline FormBIND as PayGo through RPM
Meadowbrook Insurance GroupPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
MEMIC GroupPDF FormOnline FormBIND as Comp-As-You-Go
Method InsurancePDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
MidSouth MutualPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Midwest InsurancePDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Midwestern Insurance AlliancePDF FormOnline FormBIND as PayGo through RPM
MIGPay-MerchantsPDF FormOnline FormBIND as MIGPay

National Interstate/Vanliner

PDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
National Liability & FirePDF FormOnline FormBIND Monthly Payroll Reporting
Nationwide E&S/Specialty DivisionPDF FormOnline FormBIND as PayGo through RPM
New Jersey Manufacturers InsurancePDF FormOnline FormBIND as NJM Precision Pay
New York State Insurance Fund-NYSIFPDF FormOnline FormBIND as PayGo through InsurePay/RPM
Normandy Insurance Co.PDF FormOnline FormBIND as PayGo through RPM

Ohio Bureau of Workers’ Compensation

PDF FormOnline FormBIND as Monthly Installments
Omaha National Insurance Co.PDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)

Pie Insurance

PDF FormOnline FormBIND as PayGo through RPM
PinnacolPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Preferred Employers Insurance CompanyPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)

QBE-SP

PDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)

Republic Indemnity

PDF FormOnline FormBIND as Pay-As-You-Go

Selective Insurance

PDF FormOnline FormBIND as PaySync Monthly Reporting
Service AmericanPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
SFM CompaniesPDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Stonetrust InsurancePDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
Summit (BEIC, BCIC, RFIC, BFIC)PDF FormOnline FormBIND as PayGo through RPM

Texas Mutual

PDF FormOnline FormBIND as Monthly Self-Reporting (Premiums collected per pay period)
The HartfordPDF FormOnline FormBIND as Payroll Billing SPRS-RPM
Travelers Indemnity Co.PDF FormOnline FormBIND as TravPay

UPMC/WorkPartners

PDF FormOnline FormBIND as PayGo through SmartPay/RPM
Utica NationalPDF FormOnline FormBIND as RightPay

Zenith Insurance Company

PDF FormOnline FormBIND as PayGo through SmartPay/RPM

 

*This list includes most of the carriers currently insuring our clients.  Inclusion on this list doesn’t imply endorsement of legal obligations to RPM from any specific carrier. If you do not see a particular carrier on this list and would like to know more, please contact us.

payment method change form

The RPM Payment Method Change Form must be completed, signed, and submitted in order for RPM to change your payment method. Please allow up to 1 business day for this change to take effect.

Download Payment Method Change Form    Complete Payment Method Change Form Online

Click or drag a file to this area to upload.