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To enroll in a group program with CompManagement, please complete the required information in the form.

Enrollment

Policy Number

Invoice Number

Payment Details

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Total

Billing Street Address

Billing Zip Code

Credit Card Number

Credit Card Expiration

Credit Card Security Code

3-4 digit code often on back of card

Total

In the past year has this organization operating under this policy purchased, acquired, merged with or bought the assets of another Ohio organization? Yes No

Did this involve all or part of the organization? All Part

Name of the prior organization

Its policy number if known

Date of purchase

In the next two years, does this organization plan to acquire all or part of another Ohio operation or the assets of another operation? Yes No

Do you plan to purchase all or part of the organization? All Part

Name of the organization

Its policy number if known

By submitting this form electronically, I grant permission to Compmanagement to file the necessary enrollment forms with the Ohio Bureau of Workers' Compensation (bwc) for this policy and acknowledge and accept all terms and conditions of the workers' compensation service agreement. In addition, I certify that as an officer, owner, or authorized representative of the organization that the above information is true to the best of my knowledge and that this form will allow Compamanagement to validate my enrollment qualifications.

Questions? Call (800) 825-6755, option 3

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Ohio Farm Bureau Federation is a member of American Farm Bureau Federation®, a national organization of farmers and ranchers including Farm Bureau® organizations in 49 other states and Puerto Rico, and is responsible for Farm Bureau membership and programs within the State of Ohio. Ohio Farm Bureau Federation programs and services are available only to Farm Bureau members within Ohio. The political views expressed in these pages represent Ohio Farm Bureau Federation's positions on various issues as they relate to Ohio. The positions of the national Farm Bureau organization collectively are expressed through American Farm Bureau Federation. Any opinions, statements or views expressed through comments or by outside contributors are the express views of those individuals and do not necessarily represent the views of the Ohio Farm Bureau Federation.