Get Group Purchase Of Workers' Comp. Ins. Renewal App. - Pc259

Filling out the Group Purchase Of Workers' Compensation Insurance Renewal Application is a crucial step for businesses seeking to maintain their group coverage. This guide will provide you with clear instructions on how to complete the application online, ensuring a seamless submission process.

Follow the steps to complete your application effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by entering the renewal certificate of approval number at the top of the application. This information is essential for identification purposes.
3. In the Group section, provide the name of the group applying for renewal, along with the designated contact person's details. Include their name, address, phone number, and the city, state, and zip code.
4. Next, indicate the name of the administrator for the group, including their contact information, as you did for the group.
5. Fill in the common expiration or predetermined premium discount evaluation date for the group's policies, which is vital for ensuring coverage continuity.
6. List the insurance carrier that provides coverage for the group. Ensure accuracy to avoid coverage issues.
7. Enter the names of the business entities included in the group in the designated fields, specifying their location.
8. For each business entity, fill out the corresponding policy effective date, WC governing class code, estimated premium, number of employees, and latest modifier information.
9. If there are more business entities to add, attach an additional list with the same details required for each entity.
10. After completing the application, review all the information for accuracy. Save your changes, and choose to download, print, or share the form as needed for submission.

Complete your application online today to ensure uninterrupted coverage for your group.