A comprehensive list of WCRB forms are provided below.
To see forms for a specific organization type, select the "show me" links below
Show me Agent forms
Show me Carrier forms
Show me Employer forms

Forms For Carrier Use Only

Contact Preferences

Carrier Notification Preference - Update Carrier preferred method to be notified of new NTCs, Unit Statistical Letters, Inspection Reports, Experience Rating and WCPAP Worksheets released to the web site
WCRB Business Contact Form - Update carrier contact for financial, underwriting, and unit statistical information
*NEW* WCRB Medical Data Call Contact Form - Update carrier contact for Medical Call Data information
WIFDRA Designated Contact Form - Update Wisconsin Financial Data Reporting (Financial Calls) contact information


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

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
Carrier Support Request - For carriers to request one-on-one problem resolutions
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
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
Inspection Request - Request an on-site operational review of the insured’s business
Pool Payroll Report - Pool policy holders create a Pool Payroll Report
*NEW* Premium Writing Request - Carriers report annual workers compensation premium writing

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

Worker's Compensation and Employer's Liability Policy

ACORD 101 (2008/01) - Additional Remarks Schedule
ACORD 130 (2017/05) – Workers Compensation Application
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

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
© 2022 Wisconsin Compensation Rating Bureau