Talk with a real person 
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.
Authorization For Premium Remittal FORMS LISTED BY CARRIER
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z
If you would like to inquire about a carrier not listed below, please CLICK HERE.
| Carrier Name | PDF Download | Authorization Form | BIND Instructions |
|---|---|---|---|
Acadia Insurance | PDF Form | Authorization Form | BIND as ClosePay through SmartPay/RPM |
| Acuity Insurance | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| AF Group | PDF Form | Authorization Form | BIND as AccuPremium |
| AlaCOMP | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| ALMA-American Longshore Mutual Association | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Amerisafe | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Amerisure Insurance | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| AmeriTrust Group | PDF Form | Authorization Form | BIND as Pay-As-You-Go through InsurePay |
| AmFed National | PDF Form | Authorization Form | BIND as Monthly Reporting (Premiums collected per pay period) |
| AmTrust North America | PDF Form | Authorization Form | BIND as PAYO through Reliable Premium Management |
| AmWINS Specialty | PDF Form | Authorization Form | BIND as PayGo through RPM |
| Arch Insurance | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Arrowhead-Everest | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Ascendant Insurance Solutions | PDF Form | Authorization Form | BIND as PayGo through Reliable Premium Management |
| Associated Insurance Administrators (AIA) | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| ATA Comp Fund | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Atlas General | PDF Form | Authorization Form | BIND as Atlas GoPay |
| Aura Risk Management | PDF Form | Authorization Form | BIND as Pay-As-You-Go through InsurePay |
Beacon Aviation Insurance Services | PDF Form | Authorization Form | BIND as PAYO through Reliable Premium Management |
| Beacon Mutual Insurance | PDF Form | Authorization Form | BIND as Beacon Pay-As-You-Go |
| Benchmark-American Liberty | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Benchmark-Benchmark | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Benchmark-CompStar | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Benchmark-Diamond | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Berkley Industrial Comp | PDF Form | Authorization Form | BIND as Monthly Reporting (Premiums collected per pay period) |
| Berkley Mid-Atlantic Group | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Berkley Net | PDF Form | Authorization Form | BIND as PayGo through SmartPay/RPM |
| BHHC (Berkshire Hathaway Homestate Companies) | PDF Form | Authorization Form | BIND as FlexPay |
| Builders Insurance Group | PDF Form | Authorization Form | BIND as PayGo through RPM |
| Builders Mutual Insurance Company | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
CA State Compensation Insurance Fund | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Chesapeake Employers Insurance | PDF Form | Authorization Form | BIND as PayGo through SmartPay/RPM |
| Clear Spring – CCMSI | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Clear Spring – Paragon | PDF Form | Authorization Form | BIND as PayGo through RPM |
| Clear Spring – Tangram | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| C.N.A. Insurance | PDF Form | Authorization Form | BIND as C.N.A. Payroll Reporting |
| Cimarron | PDF Form | Authorization Form | BIND as PayGo through RPM |
| Clear Spring Property & Casualty | PDF Form | Authorization Form | BIND as Pay-As-You-Go through InsurePay |
| CopperPoint Insurance | PDF Form | Authorization Form | BIND as CopperPay (Premiums collected per pay period) |
| Crum & Forster | PDF Form | Authorization Form | BIND as PayGo through SmartPay/RPM |
Employers | PDF Form | Authorization Form | BIND as PrecisePay |
| Encova Insurance | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Erie Insurance | PDF Form | Authorization Form | BIND as Erie PaySense |
| Everest National | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
Farmers Insurance | PDF Form | Authorization Form | BIND as Farmers Real-Time Billing |
| FCBI Fund | PDF Form | Authorization Form | BIND as PayGo through RPM |
| FCCI | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| FFVA | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| FHM | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| First Benefits Insurance Mutual | PDF Form | Authorization Form | BIND as PayGo through RPM |
| Frank Crum | PDF Form | Authorization Form | BIND as PayGo through RPM |
| FUBA | PDF Form | Authorization Form | BIND as PayGo through RPM |
Grange Insurance | PDF Form | Authorization Form | BIND as Pay As You Go |
| Great American Insurance Co | PDF Form | Authorization Form | BIND as Monthly Reporting (Premiums collected per pay period) |
| GUARD Insurance Group | PDF Form | Authorization Form | BIND as GRIP-Reliable Premium Management |
Hanover Insurance Company | PDF Form | Authorization Form | BIND as Hanover EZPay |
| Hartford | PDF Form | Authorization Form | BIND as XactPay Self-Reporting |
| Hawaii Employer’s Mutual Insurance Company | PDF Form | Authorization Form | BIND as AePay |
| Highview National | PDF Form | Authorization Form | BIND as PayGo through RPM |
ICW Group | PDF Form | Authorization Form | BIND as EZ Report through RPM |
| Insurate | PDF Form | Authorization Form | BIND as Monthly Reporting (Premiums collected per pay period) |
| Isurity | PDF Form | Authorization Form | BIND as Monthly Reporting (Premiums collected per pay period) |
Key Risk Insurance | PDF Form | Authorization Form | BIND as PayGo through RPM |
Lackawanna Casualty Company | PDF Form | Authorization Form | BIND as Monthly Self-Reporter (Premiums collected per pay period) |
| Liberty Mutual | PDF Form | Authorization Form | BIND as Monthly Self-Reporter (Premiums collected per pay period) |
| LUBA Workers’ Comp | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
Main Street America Insurance | PDF Form | Authorization Form | BIND as Pay-As-You-Go through InsurePay |
| Markel Insurance | PDF Form | Authorization Form | BIND as Markel Specialty through SmartPay |
| MCIM (Michigan Commercial Insurance Mutual) | PDF Form | Authorization Form | BIND as PayGo through RPM |
| Meadowbrook Insurance Group | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| MEMIC Group | PDF Form | Authorization Form | BIND as Comp-As-You-Go |
| Method Insurance | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| MidSouth Mutual | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Midwest Insurance | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Midwestern Insurance Alliance | PDF Form | Authorization Form | BIND as PayGo through RPM |
| MIGPay-Merchants | PDF Form | Authorization Form | BIND as MIGPay |
National Interstate/Vanliner | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| National Liability & Fire | PDF Form | Authorization Form | BIND Monthly Payroll Reporting |
| Nationwide E&S/Specialty Division | PDF Form | Authorization Form | BIND as PayGo through RPM |
| New Jersey Manufacturers Insurance | PDF Form | Authorization Form | BIND as NJM Precision Pay |
| New York State Insurance Fund-NYSIF | PDF Form | Authorization Form | BIND as PayGo through InsurePay/RPM |
| Normandy Insurance Co. | PDF Form | Authorization Form | BIND as PayGo through RPM |
| NSM Insurance | PDF Form | Authorization Form | BIND as Pay-As-You-Go through InsurePay |
Ohio Bureau of Workers’ Compensation | PDF Form | Authorization Form | BIND as Monthly Installments |
| Omaha National Insurance Co. | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
Pie Insurance | PDF Form | Authorization Form | BIND as PayGo through RPM |
| Pinnacol | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| PMA Insurance | PDF Form | Authorization Form | BIND as PayGo through SmartPay/RPM |
| Preferred Employers Insurance Company | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Protective Insurance | PDF Form | Authorization Form | BIND as RightSum |
QBE-SP | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
Republic Indemnity | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Rockwood | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
Selective Insurance | PDF Form | Authorization Form | BIND as PaySync Monthly Reporting |
| Service American | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| SFM Companies | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Starr Insurance | PDF Form | Authorization Form | BIND as Pay-As-You-Go through InsurePay |
| Stonetrust Insurance | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Summit (BEIC, BCIC, RFIC, BFIC) | PDF Form | Authorization Form | BIND as PayGo through RPM |
| Summit Premier | PDF Form | Authorization Form | BIND as PayGo through RPM |
Texas Mutual | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Travelers Indemnity Co. | PDF Form | Authorization Form | BIND as TravPay |
UPMC/WCF Insurance | PDF Form | Authorization Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Westfield Insurance | PDF Form | Authorization Form | BIND as Pay-As-You-Go through InsurePay |
| Workers Compensation Trust | PDF Form | Authorization Form | BIND as Pay-As-You-Go through InsurePay |
| WorkPartners | PDF Form | Authorization Form | BIND as PayGo through SmartPay/RPM |
| Utica National | PDF Form | Authorization Form | BIND as RightPay |
Zenith Insurance Company | PDF Form | Authorization Form | BIND as PayGo through SmartPay/RPM |
| Zurich-SP | PDF Form | Authorization Form | BIND as Monthly Reporting (Premiums collected per pay period) |
*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.
