Certificate of Participation Request Form:

Your Company (Member) Name:

Member Password (same as to submit claims):

Don't remember your password?  E-mail Sue at smorang@workerscompme.com 

CERTIFICATE HOLDER INFORMATION:

Company Name:

Address:

City:   State:    Zip Code:

Fax Number:  Attention:

NOTE: If you would like us to send you an e-mail confirming your Certificate request has been sent, please indicate your e-mail before submitting the form:

Your e-mail address:

WE WILL MAKE EVERY EFFORT TO SATISFY CERTIFICATE REQUESTS WITHIN 24 BUSINESS HOURS - MONDAY THROUGH FRIDAY 8:00AM - 5:00PM EST.

QUESTIONS? E-MAIL SUE AT smorang@workerscompme.com