NOTE: THIS NEEDS TO BE REPRODUCED
ON YOUR COMPANY LETTERHEAD AND BE SIGNED BY AN OFFICER OF THE COMPANY
Date
To whom it May Concern
This letter authorizes you to release to Advanced Insurance Management information you have on file regarding our workers compensation policies, payroll audits, auditor’s worksheets, and experience modification calculations. This includes electronic access to information on file with NCCI regarding our company’s Workers Compensation experience modifiers, classifications, and other data about our company.
Please comply with their request for this information.
By,
Signature
Title
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