Utah County Insurance Pool

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Workers' Compensation Renewal Information – 2009

In order to provide premium quotes to UCIP members by September (for budgeting purposes) please submit the following information no later than August 31. Contact Sonya White with any questions at the number listed below.

Submitted By
Name:
Title:
County:
Phone Number:
Email:
Total Estimated Payroll
Clerical:	$
County:	$
Firefighters:	$
Road:	$
Total Incurred Losses
2003:	$
2004:	$
2005:	$
2006:	$
2007:	$
(do not report losses for the year(s) your County has been insured by the Pool)