Group Enrollment

To enroll in a group program with Sedgwick, please complete the required information then click the Submit button to view your enrollment forms. You will then be linked to a secured PayPal site where your payment will be processed online. If you have any questions, please call Sedgwick’s Customer Support Unit at (800) 825-6755, option 3.

Note: Required fields are designated with an asterisk (*).

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* Group Type:	GroupRatingGroupRetroSedgwickServices
* Contact Name:
* Contact Title:
* Contact Phone #:
* Contact Email:
* Company Name:
* Company Address:
* Company City:	State: AA AE AK AL AP AR AS AZ CA CO CT DC DE FA FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY ZIP:
* BWC Policy Number:	***Located on your Sedgwick Invoice
Sedgwick Invoice #:	***Located on your Sedgwick Invoice
* Fee Amount: $	***Located on your Sedgwick Invoice

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* 1) 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

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* 2) 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

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By submitting this form electronically, I grant permission to Sedgwick 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 Sedgwick to validate my enrollment qualifications.

Note: No further documentation is required to be sent for enrollment. After payment is made, a confirmation email will be sent.