Fill out the following form to submit your Workers’ Compensation business. Agency Name*Submission Type*State Compensation Insurance FundWholesale Workers' CompAgent Contact* First Last Email* PhoneEffective Date MM DD YYYY Target PremiumNeed by Date MM DD YYYY Upload DocumentsPlease upload the Application, 4-Year Loss Runs, and Supplemental. Upload limit: 128MB. Drop files here or Accepted file types: pdf, doc, docx, jpg, png, xls, xlsx, csv, txt. Please provide any additional information
