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Authority: I, (as stated in the Primary Contact Section) by signing this form agree for Employers Comp PTY LTD and its representative to review my eligibility in my state or territory of operation for Workers Compensation with an approved nominal provider. I, (as stated in the Primary Contact Section), or my authorized representative, on behalf of the employer (as stated in the Company Section) request Employers Comp to contact me if further information is required, by telephone or email. I, (as stated in the Primary Contact Section), or my authorized representative, on behalf of the employer (as stated in the Company Section) request Employers Comp to provide me with an estimate of costs for ongoing services and support if applicable.

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