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 (*).
* Group Type:
GroupRating
GroupRetro
SedgwickServices
Group Rating, Group Retro, or Sedgwick Services must be selected
* Contact Name:
* Contact Title:
* Contact Phone #:
* Contact Email:
Please enter valid email address.
* 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
BWC policy must be numeric.
Sedgwick Invoice #:
***Located on your Sedgwick Invoice
Invoice must be numeric.
* Fee Amount: $
***Located on your Sedgwick Invoice
Please Enter Amount in Valid Format. 9999.99
* 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
Invalid date - Use format MM/DD/YYYY.
* 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
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.