Rating Values Form

Contact Name*

Contact Phone Number*

Contact Email*

Carrier Name(s) - please use punctuation between each name.*

Carrier Number(s) - please use punctuation between each number.
Note: Do not supply NAIC number.*

Please indicate experience rating values:*

2021 Data Collection Agency - Pure Premiums

2021 Assigned Risk Rating Values

Other

If Other, please explain:

Effective Date:*

Fill out the form as complete as possible. For further information contact Jeannine Paquet at 734-462-9600 (EXT 229) or jpaquet@caom.com.