Get Started | Premium Pilot

Five short sections. Have your policy and your bank details to hand.

Getting started

Which describes you?

I am a policyholder or business owner I am an insurance agent or carrier

Your business

Authorized signer name

I, the undersigned, certify that I am an authorized representative of the company listed below (the "Company") and that I have the authority to enter into this agreement on the Company's behalf. I authorize Premium Pilot to calculate, collect, and remit the Company's workers' compensation premiums. I authorize Premium Pilot to automatically deduct these payments and remit to my insurance carrier. I authorize my insurance carrier and insurance agent to share my policy documents and information with Premium Pilot. I acknowledge that I will grant Premium Pilot access to the Company's payroll and workers' compensation policy information, and that Premium Pilot may share that data with my listed insurance carrier, agent, and payment processors, for the purposes of my pay-as-you-go service.

Company name, as listed on the policy

FEIN

Your nine-digit federal employer identification number.

Business address

Street 1

Street 2 (optional)

City

ZIP

State

Company contact name

Contact email

Contact phone number

Policy and payroll

Insurance agent or broker name

Insurance agent or broker email

Carrier name

Policy number

Policy effective date

Upload your policy (optional)

Drag and drop your policy here, or choose a file.

PDF, PNG or JPG, up to 8 MB.

Payroll provider

I authorize Premium Pilot to access, store, and report our payroll data in order to facilitate our workers' comp insurance billing.

How often do you run payroll?

Weekly Bi-weekly Semi-monthly

Select your payroll provider

Payroll client ID

Your company's account ID with your payroll provider (sometimes called a client ID or company code). Check your payroll portal's account or company settings.

Payment setup

Premium Pilot is designed to save the Company time and money with workers' comp. Our pricing is simple: a flat $10 fee with each payroll run. Pricing is subject to change per Premium Pilot's Terms and Conditions.

Payment method ACH debit

I authorize Premium Pilot to initiate ACH transactions to debit or credit the Company's business bank account below. Company agrees not to dispute any debits with its bank, provided the transaction(s) correspond to the terms indicated in this Agreement. In the event a transaction is returned or rejected for any reason, including but not limited to Non-Sufficient Funds, Company understands Premium Pilot may attempt to process the transaction again up to two (2) times following the original return within 30 days, in accordance to applicable ACH network rules, and agrees to an additional $40 charge for attempted return payments. Company certifies that the business bank account below is enabled for ACH transactions and agrees to reimburse Premium Pilot for any penalties or fees incurred as a result of Company's bank rejecting ACH debits or credits. Company shall also notify Premium Pilot of any payment method changes in writing or via email.

Company's name on account

Bank name

Bank routing number

Bank account number

Review and sign

By signing below, I (on behalf of the Company) acknowledge the following:

in order to maintain pay-as-you-go billing, the Company must grant Premium Pilot access to the Company's payroll reports and workers compensation policy; in the absence of either, I understand Premium Pilot will charge an account reconnection fee, while attempting to re-establish access to my payroll system or re-obtain policy information;
I can cancel my services with Premium Pilot at any time by written notice over email or on Premium Pilot's website; Premium Pilot will continue to provide the services in this Agreement until I provide notice of cancellation; upon termination, Premium Pilot will suspend services after the payroll cycle immediately following delivery of notice of termination, and will remit all collected premiums to my insurance carrier on file;
Premium Pilot will take reasonable steps to keep my worker's comp policy in good standing with my insurance carrier, provided that a funded payment method and current payroll data remain accessible to Premium Pilot. Depending on my carrier's policies, this may include assessing fixed minimum or fixed estimated premium payments to keep my policy active, even if the Company has no payroll for the applicable time period;
Premium Pilot's regular admin fee will continue to apply at all times;
Premium Pilot is a billing intermediary, responsible for estimating, collecting and remitting premiums;
Premium Pilot is not my insurance carrier or insurance agent of record, and is not responsible for policy lapses resulting from insufficient funds, inaccessible payroll data, or carrier actions outside Premium Pilot control;
Premium Pilot can assist with audit preparation and review on the Company's behalf; however, audit premium determinations are made solely by insurance carriers and auditors;
Premium Pilot is not responsible for any balance due resulting from a carrier audit; and
I have reviewed and accepted the full Premium Pilot Terms & Conditions available at getpremiumpilot.com

Signature

Type your signature

Or upload an image of your signature

Name

Title

Signature date