Workers' Compensation Security Fund 2009 Assessment Refund Application Form

Please complete the following application to request a refund of the 2009 WCSF Assessment.

It is very important that the information submitted below is accurate and complete. Prior to submitting the refund application, carriers are strongly encouraged to contact the WCSF at RA-IN-WCSFAssessRef@pa.gov to review required application information and thoroughly review the information on the Department's dedicated 2009 Assessment Refund webpage. Incorrectly entered information may result in refund processing delays and/or rejections.

*Please note: A separate refund application must be submitted for each carrier assessed in 2009.

2009 Assessed Carrier Information

Please complete the questions in this section based on the carrier information as it was assessed in 2009.

2009 Assessed Carrier Company Name

2009 Assessed Carrier NAIC #

2009 Assessed Carrier Company FEIN #

Carrier’s Payment Amount for 2009 WCSF assessment

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