WCRB Medical Data Call Contact Form

Carriers submit this form to designate or change an existing Medical Data Call contact. When this form is successfully submitted, the requestor email address will receive an emailed receipt confirmation.

If you have any questions regarding the use of this form, please contact WCRB via email at medical.data@wcrb.org or by phone at (262) 796-4420.

Member Information

Carrier ID (NCCI #):

Carrier Name:

Requestor Information

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

This is my contact for the Medical Data Call

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

Email Address: Invalid email address Email required

Street Address: Address required

City: City required

State: Zip: Zip required