WIFDRA Designated Contact Form

All carriers are required to have current a WIFDRA (Wisconsin Financial Data Reporting Application) Designated Contact Form on file with WCRB. The contact person acts as a contact between the Carrier and the Bureau for purposes of coordinating and accomplishing timely and accurate submissions of financial data for all carriers included within their carrier group. It is essential that all designated contact information for your organization is current and accurate.

The WIFDRA Designated Contact person does not have to be responsible for filling out financial calls, but will be responsible for seeing that calls are submitted on a timely basis, securing responses to questions posed by WCRB with respect to their group’s financial calls.

WIFDRA will retain Carrier Designated Contact e-mail addresses for communication of edit failures and/or questions pertaining to actuarial anomalies. User IDs and passwords will be created for all Designated Contact people

If you have any questions, contact WCRB via e-mail at financial.calls@wcrb.org

Group Information

Carrier ID (NCCI #):

Carrier Name:

Contact Name: Contact name required

Title: Contact title required

Phone#: () - Phone area code required Valid area code required Phone prefix required Valid prefix required Phone suffix required Valid suffix required

E-mail Address: Invalid e-mail address E-mail required

Street Address: Address required

City: City required

State: Zip: Zip required