PA Workers' Comp Forms

Class Codes

• Class code listing for PA and DE.

• Class code listing for MD.

Forms

• Fax Cover Sheet: ARI Quote Request  (use with each submission) 
• ACORD 130 Application

New Business Submission Process

• Verify eligiblity by reviewing the class code list and underwriting guidelines before submitting to ARI.
  

• Fax or e-mail the completed Acord 130 with the Inclusion or Exclusion form, if applicable, along with IA&B Fax Cover Quote Request sheet (available above for download) to:

Fax:    (973) 261-9202 Attention Underwriting

E-mail: maryellen.mazzo@agencyresources.com 
or florencia.robledo@agencyresources.com

Phone:  (866) 454-9676 ext. 9072 or 9073

• Anticipate a faxed response from Agency Resources, Inc. within 24 hours.
  

• Fax back an acceptance to:  Agency Resources, Inc. 
  Fax:  (973) 261-9202
  

• Anticipate a faxed binder from Agency Resources, Inc. within 24 hours. The carriers will bill the client directly.

Licensing and other Reference Tools

• Delaware Licensing Q&A
• Maryland Licensing Q&A
• Pennsylvania Licensing (Act 147) Q&A
• Pennsylvania Sample Brokerage Agreement (IA&B member login required)