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State for this inquiry
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and
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Name of Employer
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are required.
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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
*
Employer Information
Name of Employer:
*
Bureau File #:
*
Numeric Only
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Employer's Carrier:
*
Employer's Policy Number:
*
Effective Date:
*
mm/dd/yyyy
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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:
*
xxx-xxx-xxxx
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Your Email Address:
*
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Confirm Email Address:
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Attachments:
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2.
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Brief description of issue or question:
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