WISCONSIN CONTRACTORS PREMIUM ADJUSTMENT PROGRAM (WCPAP)
Premium Credit Factor Application

This application may be rejected if it does not contain information for all WC Code numbers, all Wisconsin wage information, all Wisconsin hours worked for all Wisconsin employees for all commonly owned businesses, and signature.
APPLICATIONS NOT SUBMITTED TO WCRB BY THE DUE DATE WILL BE REJECTED
Please review instructions before completing this application.
Coverage ID* Coverage ID Lookup
Employer Name*  
Address*  
City*  
State*
Zip Code*
Employer Email*
Verify Employer Email*
The information period should be based on actual base wages and regular hours worked, as reflected in your payroll records, for the 3rd Qtr (July - September) 2018 or 2017 if there were no contracting operations during 2018.
CLASS CODE INFORMATION CAN BE FOUND ON YOUR WORKER’S COMPENSATION INSURANCE POLICY.
WC CODE
NUMBERS
CODE DESCRIPTION TOTAL 3RD QTR
BASE WAGES PAID
3rd Qtr of  
TOTAL 3RD QTR
HOURS WORKED
VERIFIED
[CLEAR] $ .   .  
[CLEAR] $ .   .  
[CLEAR] $ .   .  
[CLEAR] $ .   .  
[CLEAR] $ .   .  
[CLEAR] $ .   .  
[CLEAR] $ .   .  
[CLEAR] $ .   .  
[CLEAR] $ .   .  
[CLEAR] $ .   .  
Click to add additional class code entry rows
View wage limitations for executive officers, partners, sole proprietors or members
Are the salaries of the covered corporate officers included?
This application is the
Does this application contain all the information for each entity insured under the above listed policy? If no, please explain.
Signature*:   Position*:  

Phone*: () -   Date: 12/16/2018
BY SUBMITTING THIS APPLICATION THROUGH THIS WEB SITE, THE APPLICANT IS CONSENTING TO APPLY FOR PREMIUM CREDIT IN ELECTRONIC FASHION FOR THIS SPECIFIC TRANSACTION. THE ELECTRONIC SIGNATURE CONTAINED WITHIN THIS APPLICATION IS ENFORCEABLE AND CANNOT BE DENIED LEGAL EFFECT PURSUANT TO WIS. STAT. 137.15(1).
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