Fill out the following form to submit your Workers’ Compensation business. Agency Name* Submission Type* State Compensation Insurance Fund Wholesale Workers' Comp Agent Contact* First Last Email* PhoneEffective Date Month Day Year Target PremiumNeed by Date Month Day Year Upload DocumentsPlease upload the Application, 4-Year Loss Runs, and Supplemental. Upload limit: 128MB. Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, xls, xlsx, csv, txt, Max. file size: 64 MB. Please provide any additional information
