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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 Form BIND as ClosePay through SmartPay using RPM. List Reliable Premium Management as the approved payroll vendor with SmartPay.
Acuity InsurancePDF FormOnline Form BIND policy as: “Monthly Self Reporting.” Premiums will be collected on a per pay period basis.
AF GroupPDF FormOnline Form BIND as “AccuPremium.” Note to Policyholder: Select “Reliable Premium Management” as the Payroll Provider when registering policy.
AlaCOMPPDF FormOnline Form BIND policy as: “Payroll Reporting.”
ALMA-American Longshore Mutual AssociationPDF FormOnline Form BIND policy as: “Monthly Self-Reporting.” Premiums will be collected on a per pay period basis.
Amerisure InsurancePDF FormOnline Form BIND policy as: “Monthly Self Reporting.” Premiums will be collected on a per pay period basis.
AmTrust North AmericaPDF FormOnline Form BIND as “PAYO through Reliable Premium Management.”
AmWINS SpecialtyPDF FormOnline Form BIND as “PAY-GO through RPM.”
Arch InsurancePDF FormOnline Form BIND policy as: “Monthly Self-Reporting.” Premiums will be collected on a per pay period basis.
Arrowhead-EverestPDF FormOnline Form BIND policy as: “Monthly Self Reporting.”
Ascendant Insurance SolutionsPDF FormOnline Form BIND policy as: “PAY-GO through Reliable Premium Management.”
Atlas GeneralPDF FormOnline Form BIND as “Atlas GoPay.” Note to Policyholder: Select “Reliable Premium Management” as the Payroll Provider when registering policy.

Beacon Aviation Insurance

Services

PDF FormOnline Form BIND
Beacon Mutual InsurancePDF FormOnline Form BIND
Benchmark-American LibertyPDF FormOnline Form BIND
Benchmark-BenchmarkPDF FormOnline Form BIND
Benchmark-CompStarPDF FormOnline Form BIND
Benchmark-DiamondPDF FormOnline Form BIND
Berkley Mid-Atlantic GroupPDF FormOnline Form BIND
Berkley NetPDF FormOnline Form BIND
BHHC (Berkshire Hathaway Homestate Companies)PDF FormOnline Form BIND
Builders Insurance GroupPDF FormOnline Form BIND
Builders Mutual Insurance CompanyPDF FormOnline Form BIND

CA State Compensation Insurance Fund

PDF FormOnline Form BIND
Chesapeake Employers InsurancePDF FormOnline Form BIND
Clear Spring – CCMSIPDF FormOnline Form BIND
Clear Spring – ParagonPDF FormOnline Form BIND
Clear Spring – TangramPDF FormOnline Form BIND
C.N.A. InsurancePDF FormOnline Form BIND
CimarronPDF FormOnline Form BIND
Crum & ForsterPDF FormOnline Form BIND

Employers

PDF FormOnline Form BIND
Erie InsurancePDF FormOnline Form BIND
Everest NationalPDF FormOnline Form BIND

Farmers Insurance

PDF FormOnline Form BIND
FCBI FundPDF FormOnline Form BIND
FCCIPDF FormOnline Form BIND
FFVAPDF FormOnline Form BIND
FHMPDF FormOnline Form BIND
First Benefits Insurance MutualPDF FormOnline Form BIND
Frank Crum General AgencyPDF FormOnline Form BIND
FUBAPDF FormOnline Form BIND

Grange Insurance

PDF FormOnline Form BIND
GUARD Insurance GroupPDF FormOnline Form BIND

Hanover Insurance Company

PDF FormOnline Form BIND
Hawaii Employer’s Mutual Insurance CompanyPDF FormOnline Form BIND

ICW Group

PDF FormOnline Form BIND

Key Risk Insurance

PDF FormOnline Form BIND

Lackawanna Casualty Company

PDF FormOnline Form BIND
Liberty MutualPDF FormOnline Form BIND
LUBA Workers’ CompPDF FormOnline Form BIND

Markel Insurance

PDF FormOnline Form BIND
MCIM (Michigan Commercial Insurance Mutual)PDF FormOnline Form BIND
Meadowbrook Insurance GroupPDF FormOnline Form BIND
MEMIC GroupPDF FormOnline Form BIND
Method InsurancePDF FormOnline Form BIND
MidSouth MutualPDF FormOnline Form BIND
Midwest InsurancePDF FormOnline Form BIND
Midwestern Insurance AlliancePDF FormOnline Form BIND
MIGPay-MerchantsPDF FormOnline Form BIND

National Interstate/Vanliner

PDF FormOnline Form BIND
National Liability & FirePDF FormOnline Form BIND
Nationwide E&S/Specialty DivisionPDF FormOnline Form BIND
New Jersey Manufacturers InsurancePDF FormOnline Form BIND
New York State Insurance Fund-NYSIFPDF FormOnline Form BIND
Normandy Insurance Co.PDF FormOnline Form BIND

Ohio Bureau of Workers’ Compensation

PDF FormOnline Form BIND
Omaha National Insurance Co.PDF FormOnline Form BIND

Pie Insurance

PDF FormOnline Form BIND
PinnacolPDF FormOnline Form BIND
Preferred Employers Insurance CompanyPDF FormOnline Form BIND

QBE-SP

PDF FormOnline Form BIND

Republic Indemnity

PDF FormOnline Form BIND

Selective Insurance

PDF FormOnline Form BIND
Service AmericanPDF FormOnline Form BIND
SFM CompaniesPDF FormOnline Form BIND
Stonetrust InsurancePDF FormOnline Form BIND
Summit (BEIC, BCIC, RFIC, BFIC)PDF FormOnline Form BIND

Texas Mutual

PDF FormOnline Form BIND
The HartfordPDF FormOnline Form BIND
Travelers Indemnity Co.PDF FormOnline Form BIND

UPMC/WorkPartners

PDF FormOnline Form BIND
Utica NationalPDF FormOnline Form BIND

Zenith Insurance Company

PDF FormOnline Form BIND

 

*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.