Forms, Endorsements, WCPAP Application, Notification Forms - Wisconsin Compensation Rating Bureau

Forms For Carrier Use Only

Contact Preferences

Carrier Notification Preference - Experience Rating - Update carrier preferred method of Experience Rating Worksheet release notification

Carrier Notification Preference - Inspection Report - Update carrier preferred method of Inspection Report release notification

Carrier Notification Preference - NTC - Update carrier preferred method of Notice to Carrier (NTC) release notification

Carrier Notification Preference - Unit Statistical Letter - Update carrier preferred method of Unit Statistical letter notification

Carrier Notification Preference - WCPAP Worksheet - Update carrier preferred method of WCPAP Worksheet letter notification

WCRB Business Contact Form - Update carrier contact for financial, underwriting, and unit statistical information

WIFDRA Designated Contact Form - Update Wisconsin Financial Data Reporting (Financial Calls) contact information

Elections

Carrier Elections - Provide carrier election information. The Carrier Election member product is only available to carrier members. Please contact the Group Administrator for your carrier group to request access to this member product.

Filing Option Election Form - Complete and submit to file unit statistical data directly with WCRB

Policy Related

Premium Writing Request - Carriers report current year's workers compensation premium writing

Wisconsin Notice of Termination C1-0062 - Carriers use to provide a Notice of Termination

Wisconsin Notice of Reinstatement C2-0062A (2002) - Carriers use to provide a Notice of Reinstatement

Endorsements

Endorsements Acceptable in Wisconsin - Standard endorsements accepted in Wisconsin

Endorsements N/A in Wisconsin - Listing of endorsements not accepted in Wisconsin

Reporting and Miscellaneous Requests

Bureau Request Form - Request employer specific information such as rating or experience modification data or five-year premium and loss exhibit, etc.

Business Operations Report - Insureds use to provide self inspection business operation details

Employer 'FindMyMod' Access Request - Misplaced your Employers Experience Rating access instruction letter? Request WCRB to resend.

ERM-6 (12/7/04) - Self-insureds use to submit experience rating data

*NEW* Electronic ERM-14 (Hardcopy ERM-14) (Detailed ERM-14 Instructions) - Insureds use to report ownership changes

Information Release Authorization Form - IRAF (5/9/06) - Allows insureds to authorize WCRB to release information to a designated entity

*NEW* Inspection Request - Request an on-site operational review of the insured’s business

Pool Payroll Report - Pool policy holders create a Pool Payroll Report

WCRB Web Membership

Authorizing Officer Change Form - Replace the existing Authorizing Officer for your organization

Group Administrator Change Request - Replace the existing Group Administrator for your organization

WCRB Group Administrator Web Account Registration - Complete to establish a WCRB Web site membership

Web Site Member User Guide - User Guide for WCRB Web site members and a listing of products afforded to each membership level

Wisconsin Worker's Compensation Insurance Pool

ACORD 134 WI - Wisconsin Supplementary Non-Election Form

ACORD 135 WI - Wisconsin Supplementary Election of Coverage Form

ACORD 136 WI - Wisconsin Supplementary Limited Other States Coverage Request

WI Pool V 1.0 - Wisconsin Worker's Compensation Insurance Pool hard copy application

Wisconsin Contractors Premium Adjustment Program (WCPAP)

WCPAP.ED11 - WCPAP Premium Credit Factor Online Application

For assistance, please call 262-796-4593

WCPAP-ED02-16-17 - WCPAP Carrier Audit Form

Worker's Compensation and Employer's Liability Policy

ACORD 101 (2008/01) - Additional Remarks Schedule

WC 00 00 00 C (Ed. 1-15) - Worker's Compensation and Employers Liability Insurance Policy language

WC 00 00 01 A - Information Page - Worker's Compensation and Employers Liability Insurance Policy information page

WC 00 00 01 A - General Information Page Notes - General Information Page Notes

WC 00 00 01 C - Information Page Notes - Information Page Notes

Wisconsin Proof of Coverage (48-2) - For use when providing evidence of coverage on a rewritten policy which is not immediately available

Worker's Compensation Excess Policy

CKE-1167M (01-15) - Specific Excess Workers Compensation and Employers Liability Policy

00 GL0253 50 (04 15) - Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement

EX 00 01 09 08 - Excess Policy for Self Insured

00 GL0367 50 (05 15) - Designated Workplaces Exclusion Endorsement

WCE 90 00 03 (SC) Ed. 01/96 - Specific Excess and Aggregate Excess

00 GL0368 50 (04 15) - Excess Voluntary Compensation and Employers Liability Coverage Endorsement

WC 99 05 57 (01-15) - Cancellation Form

00 GL0403 50 (05 15) - Amendatory Endorsement

WC 99 05 64 (07-15) - Reporting of Data on Claims

WC 99 06 T5 (00) - Catastrophe Premium Endorsement

WC 99 06 T6 (00) - Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement

XS WC 0001-0002 WI (10/14) - Excess Workers Compensation & Employers Liability Coverage Form

XWC 202-XLSP 0813 - Stop Gap Insurance Endorsement

XWC 223-XLSP 813 - Maritime Coverage Endorsement