::WCRIBMA Home	At least 1 policy from either policies at 1st, 2nd, or 3rd must be chosen

Combo Group ID#		Must be 9 digits or less
Rating Effective Date (MM/DD/YYYY)		Must be a valid date before the current date + 210 daysInvalid Date Format Required
Interstate Indicator	Yes No	View Policy Date Range(click to refresh)
Number of policies at 1st	0 1 2 3 4 5 6 7 8 9 10
Number of policies at 2nd	0 1 2 3 4 5 6 7 8 9 10
Number of policies at 3rd	0 1 2 3 4 5 6 7 8 9 10
User's Name		Required
Employer's Name

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