Employer Forms

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

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
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