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 current carrier election information Now located here
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, inspection reports, etc.
ERM-14 (12/7/04) - 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 130 (2013/09) - Workers Compensation and Employers Liability Insurance Policy application (ACORD application Form 133 must be used for Pool business)
ACORD 130 (2017/05) - Workers Compensation and Employers Liability Insurance Policy application (ACORD application Form 133 must be used for Pool business)
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