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Policy Reporting Inquiry
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= 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
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Pennsylvania
Delaware
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Employer Information
Name of Employer:
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Bureau File #:
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Employer's Carrier:
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Employer's Policy Number:
*
Effective Date:
*
mm/dd/yyyy
Your Information
Your Name:
*
Your Affiliation:
-- Select One --
Carrier Of Record
Carrier
Agent/Broker Of Record
Agent/Broker
Employer
Other
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Your Company's Name:
Your Company's Mailing Address:
Your Phone Number:
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xxx-xxx-xxxx
Your Email Address:
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Confirm Email Address:
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Attachments:
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Brief description of issue or question:
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