Group Enrollment Questionnaire

To enroll in a group with CompManagement, please fill out the form below with the required information then click on the Submit button. You will be linked to a secured PayPal site where your payment can be processed online. If you have any questions, please call CMI’s Customer Support Unit at 1-800-825-6755, option 3.

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

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* Contact Name:
* Contact Phone #:
Contact Email:
* Company Name:
* BWC Policy Number:	***Located on your CMI Invoice
CMI Invoice #:	***Located on your CMI Invoice
* Fee Amount: $	***Located on your CMI Invoice

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* 1) Please indicate which option below best describes your organization operating under this policy. This organization has been in operation in Ohio for over 5 years This organization began its Ohio operations as a new start-up within the past 5 years This organization began its Ohio operations through the purchase, acquisition, or merger of another Ohio organization or its assets within the past 5 years This organization has taken over the employees or location or book of business of another organization within the past 5 years

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* 2) In the past 5 years 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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* 3) In the coming year, 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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* 4) A PEO (Professional Employer Leasing Organization) provides human resources management services to other business owners. Please select the option that best describes your company.

My company is a PEO My company plans on becoming a PEO My company has been a client of a PEO Not applicable

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By submitting this form electronically, I certify that the above information is true to the best of my knowledge and that this form will allow CompManagement to validate my enrollment qualifications.

Note: No further documentation is required to be sent for enrollment. A confirmation email will be sent to you if you entered an email address above.