New Account Engagement Form

Thank you for considering ESM as your service provider!
To get started, please complete the following form.

Submitted By

First Name

Last Name

Your Email Address

Account Name

Account Address

Account Contact Name

First Name

Last Name

Account Contact Position

Account Contact Phone

Account Contact Email

X-Mod

Policy Effective Date

YYYY

Insurance Agency Name

Producer Name

First Name

Last Name

Account Manager Name

First Name

Last Name

Insurance Carrier/TPA Name

Special Instructions

Account Files

Please confirm each of the the following files are included in your upload.

Workers' Compensation Acord App

Current Loss runs (4 years if available)

Current & Prior Year X-Mod Worksheets

Prior Status Reports (if available)

Upload Files Here upload

NOTE: Please re-name all files to include the Account Name before uploading to ensure your files are bundled correctly.

Contact us today to start reducing your Workers’ Compensation risk and cost.