Employer Forms

Reporting and Miscellaneous Requests


Bureau Request Form - Request employer specific information such as rating or experience modification data, inspection reports, 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
ERM-14 (12/7/04) - 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
Pool Payroll Report - Pool policy holders create a Pool Payroll Report

Wisconsin Worker's Compensation Insurance Pool


ACORD 133 WI - Wisconsin Worker's Compensation Insurance Pool hard copy application
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

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