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facilitating premium payments

New Account Form

RPM Payment Authorization Agreement

RPM provides Pay-As-You-Go Services for policyholders that have secured coverage with one of the insurance carriers listed below. RPM works on behalf of the policyholder to facilitate premium payments based upon actual payroll.

If a policyholder is interested in authorizing RPM to commence services on behalf of their policy, they simply need to provide the information below. If the policyholder would prefer to complete a paper copy of the RPM Authorization Form, click the button below.

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RPM Authorization for Premium Remittal

My Company Information

Authorized Company Contacts

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 I understand that the following individual(s) will be notified via email prior to any charges being withdrawn from my account.

My Payroll Provider

My Servicing Insurance Agent & Policy Info

My Selected Payment Method