Carrier Notification Form

Use this form to notify the WCRB of changes for the notification of newly released Experience Rating Worksheets, Inspection Reports, NTCs, Unit Statistical Letters, and WCPAP Worksheets.

A change in contact information may be made at any time by resubmitting this form.
The information you provide below will overwrite existing contact information. If you wish to retain any contacts, please include them with your update.
A single form can be submitted for multiple carriers within a carrier group if the contacts are the same for the selected carriers.

Select one or more of the following notifications:

Select at least one notification preference

Member Information

Carrier ID (NCCI #):

Carrier Name:

Carrier Authorizing Representative Name: Contact name required

Carrier Representative Title: Contact title required

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

Carrier Representative Email Address: Invalid email address Email required

Email Address(es) to receive notifications

Max characters allowed: 98

Characters remaining: 98 * Provide at least one email address

Email address 1* :

Email address 2:*

Email address 3:*

Is this request: New Change to Existing

Effective Date: 12/14/2025

For more information contact: industry.support@wcrb.org or by phone at (262) 796-4540