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Policy Reporting Inquiry
*
= Required Fields
Enter the information below with a brief description of your inquiry.
Does your inquiry involve a particular employer?
Yes
No
State for this inquiry:
*
-- Select State --
Pennsylvania
Delaware
Employer Information
Name of Employer:
*
Name of the insured is empty or contains invalid characters
Bureau File #:
*
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Employer's Carrier:
*
Employer's Policy Number:
*
Effective Date:
*
Your Information
Your Name:
*
Your Affiliation:
*
-- Select One --
Carrier Of Record
Carrier
Agent/Broker Of Record
Agent/Broker
Employer
Other
Your Company's Name:
*
Your Company's Mailing Address:
*
Your Phone Number:
*
Your Email Address:
*
Confirm Email Address:
*
Copy To:
(
Optional
)
**Separate multiple email addresses by a comma [
,
].**
Attachments:
** Total File Size Limit: Less Than 10MB **
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2.
3.
**If you want to attach a document to your inquiry, click the "Choose File" button and select a file from your computer. You can double-click the file or click "Open" to include it with your inquiry.**
Brief description of issue or question:
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