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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.
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 | Online Form | BIND Instructions |
|---|---|---|---|
Acadia Insurance | PDF Form | Online Form | BIND as ClosePay through SmartPay/RPM |
| Acuity Insurance | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| AF Group | PDF Form | Online Form | BIND as AccuPremium |
| AlaCOMP | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| ALMA-American Longshore Mutual Association | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Amerisure Insurance | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| AmFed National | PDF Form | Online Form | BIND as Monthly Reporting (Premiums collected per pay period) |
| AmTrust North America | PDF Form | Online Form | BIND as PAYO through Reliable Premium Management |
| AmWINS Specialty | PDF Form | Online Form | BIND as PayGo through RPM |
| Arch Insurance | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Arrowhead-Everest | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Ascendant Insurance Solutions | PDF Form | Online Form | BIND as PayGo through Reliable Premium Management |
| Atlas General | PDF Form | Online Form | BIND as Atlas GoPay |
Beacon Aviation Insurance Services | PDF Form | Online Form | BIND as PAYO through Reliable Premium Management |
| Beacon Mutual Insurance | PDF Form | Online Form | BIND as Beacon Pay-As-You-Go |
| Benchmark-American Liberty | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Benchmark-Benchmark | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Benchmark-CompStar | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Benchmark-Diamond | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Berkley Industrial Comp | PDF Form | Online Form | BIND as Monthly Reporting (Premiums collected per pay period) |
| Berkley Mid-Atlantic Group | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Berkley Net | PDF Form | Online Form | BIND as PayGo through SmartPay/RPM |
| BHHC (Berkshire Hathaway Homestate Companies) | PDF Form | Online Form | BIND as FlexPay |
| Builders Insurance Group | PDF Form | Online Form | BIND as PayGo through RPM |
| Builders Mutual Insurance Company | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
CA State Compensation Insurance Fund | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Chesapeake Employers Insurance | PDF Form | Online Form | BIND as PayGo through SmartPay/RPM |
| Clear Spring – CCMSI | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Clear Spring – Paragon | PDF Form | Online Form | BIND as PayGo through RPM |
| Clear Spring – Tangram | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| C.N.A. Insurance | PDF Form | Online Form | BIND as C.N.A. Payroll Reporting |
| Cimarron | PDF Form | Online Form | BIND as PayGo through RPM |
| Crum & Forster | PDF Form | Online Form | BIND as PayGo through SmartPay/RPM |
Employers | PDF Form | Online Form | BIND as PrecisePay |
| Erie Insurance | PDF Form | Online Form | BIND as Erie PaySense |
| Everest National | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
Farmers Insurance | PDF Form | Online Form | BIND as Farmers Real-Time Billing |
| FCBI Fund | PDF Form | Online Form | BIND as PayGo through RPM |
| FCCI | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| FFVA | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| FHM | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| First Benefits Insurance Mutual | PDF Form | Online Form | BIND as PayGo through RPM |
| Frank Crum | PDF Form | Online Form | BIND as PayGo through RPM |
| FUBA | PDF Form | Online Form | BIND as PayGo through RPM |
Grange Insurance | PDF Form | Online Form | BIND as Pay As You Go |
| Great American Insurance Co | PDF Form | Online Form | BIND as Monthly Reporting (Premiums collected per pay period) |
| GUARD Insurance Group | PDF Form | Online Form | BIND as GRIP-Reliable Premium Management |
Hanover Insurance Company | PDF Form | Online Form | BIND as Hanover EZPay |
| Hartford | PDF Form | Online Form | BIND as XactPay Self-Reporting |
| Hawaii Employer’s Mutual Insurance Company | PDF Form | Online Form | BIND as AePay |
| Highview National | PDF Form | Online Form | BIND as PayGo through RPM |
ICW Group | PDF Form | Online Form | BIND as EZ Report through RPM |
| Insurate | PDF Form | Online Form | BIND as Monthly Reporting (Premiums collected per pay period) |
| Isurity | PDF Form | Online Form | BIND as Monthly Reporting (Premiums collected per pay period) |
Key Risk Insurance | PDF Form | Online Form | BIND as PayGo through RPM |
Lackawanna Casualty Company | PDF Form | Online Form | BIND as Monthly Self-Reporter (Premiums collected per pay period) |
| Liberty Mutual | PDF Form | Online Form | BIND as Monthly Self-Reporter (Premiums collected per pay period) |
| LUBA Workers’ Comp | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
Markel Insurance | PDF Form | Online Form | BIND as Markel PayGo |
| MCIM (Michigan Commercial Insurance Mutual) | PDF Form | Online Form | BIND as PayGo through RPM |
| Meadowbrook Insurance Group | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| MEMIC Group | PDF Form | Online Form | BIND as Comp-As-You-Go |
| Method Insurance | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| MidSouth Mutual | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Midwest Insurance | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Midwestern Insurance Alliance | PDF Form | Online Form | BIND as PayGo through RPM |
| MIGPay-Merchants | PDF Form | Online Form | BIND as MIGPay |
National Interstate/Vanliner | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| National Liability & Fire | PDF Form | Online Form | BIND Monthly Payroll Reporting |
| Nationwide E&S/Specialty Division | PDF Form | Online Form | BIND as PayGo through RPM |
| New Jersey Manufacturers Insurance | PDF Form | Online Form | BIND as NJM Precision Pay |
| New York State Insurance Fund-NYSIF | PDF Form | Online Form | BIND as PayGo through InsurePay/RPM |
| Normandy Insurance Co. | PDF Form | Online Form | BIND as PayGo through RPM |
Ohio Bureau of Workers’ Compensation | PDF Form | Online Form | BIND as Monthly Installments |
| Omaha National Insurance Co. | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
Pie Insurance | PDF Form | Online Form | BIND as PayGo through RPM |
| Pinnacol | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Preferred Employers Insurance Company | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Protective Insurance | PDF Form | Online Form | BIND as Monthly Reporting (Premiums collected per pay period) |
QBE-SP | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
Republic Indemnity | PDF Form | Online Form | BIND as Pay-As-You-Go |
Selective Insurance | PDF Form | Online Form | BIND as PaySync Monthly Reporting |
| Service American | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| SFM Companies | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Stonetrust Insurance | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Summit (BEIC, BCIC, RFIC, BFIC) | PDF Form | Online Form | BIND as PayGo through RPM |
Texas Mutual | PDF Form | Online Form | BIND as Monthly Self-Reporting (Premiums collected per pay period) |
| Travelers Indemnity Co. | PDF Form | Online Form | BIND as TravPay |
UPMC/WorkPartners | PDF Form | Online Form | BIND as PayGo through SmartPay/RPM |
| Utica National | PDF Form | Online Form | BIND as RightPay |
Zenith Insurance Company | PDF Form | Online Form | BIND as PayGo through SmartPay/RPM |
| Zurich-SP | PDF Form | Online 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.
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.
