Carrier Forms

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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

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.
*NEW* Electronic ERM-14 (Hardcopy ERM-14) (Detailed ERM-14 Instructions) - Insureds use to report ownership changes
*NEW* Inspection Request - Request an on-site operational review of the insured’s business

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