CPC FA

Request Types

Instructions

Reminder

Please note that we will need at least 7-14 days for processing. If needed sooner, please indicate on your request form.

Required Attachment

For this form, you must download the following Excel file, fill it out, and submit it as a file upload in this form.

Closure/Post Closure Financial Assurance

Local Number, Line of Business Number, Forms & Self Service

Please use the following downloads to correctly fill in your Local Number, Line of Business Number, and Forms & Self Service.

Help

For assistance, feel free to email RSNew@usi.com, or call 844-265-0017.

Meet Our Team

Please click here to meet our team!

Closure/Post Closure Financial Assurance

Division Number (4 digits) *

Local Number (4 digits) (For a guide, click on the "Local Number" link in the instructions to the left.)

Line of Business Number (3 digits) (For a guide, click on the "Line of Business Number" link in the instructions to the left.) *

Principal Name (Legal Entity Name) (For a guide, click on the "Legal Entity Name" link in the instructions to the left.) *

Site Name *

DBA

Electronic Submission Only

Yes

Contact Information

Name *

Email *

Phone Number *

Form Submission Details

IMPORTANT: You must download the "Closure/Post Closure Financial Assurance" spreadsheet, fill it out, save it, and upload it here. In addition, you may also upload any additional files here. *

Special Instructions

Is the due date of your request within 7 days of request submittal?

Yes

Are you a Republic employee? (Only Republic employees may submit this form.) *

Yes

*Required Fields

Request Types

Instructions

Reminder

Required Attachment

Local Number, Line of Business Number, Forms & Self Service

Meet Our Team

Closure/Post Closure Financial Assurance

Contact Information

Mailing Address, If Different Than Above

Form Submission Details