Web Service Enrollment Request

The purpose of this form is to request access to a WCRB Web Service. Individual carrier organizations may enroll for this Web Service if they are members of the bureau. (No Group enrollments accepted.)

To enroll in the CDX WCUnderwriting web service, in addition to submitting this form the carrier’s CDX primary administrator must log into their cdxworkcomp.org member account and request DCO approval in the My UMG/Web Service Setup tab.

Upon receipt of this completed form, the WCRB will initiate the Service enrollment process for the carrier.

Technical Contact

This is a technical person in your Information Technology Department who will communicate with the WCRB’s Information Technology Department. This person should have a thorough understanding of the carrier member’s information technology systems and have the authority to receive the user ID and password associated with the requested Web Service.

First Name:   Last Name:  

Title:   Phone Number: () -

E-mail Address:

Verify E-mail:

Authorizing Officer

This must be an officer authorized to legally bind the Carrier organization to the Web Services Agreement.

First Name:   Last Name:  

Title:  

Note: The 5 digit bureau membership Carrier ID can be found in the WI Active Carrier List. This is not your NAIC Carrier Code.

Mailing Address (Street or PO Box):  

City:   State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:  

Phone Number: () -

E-mail Address:

Verify E-mail:

BY SUBMITTING THIS APPLICATION THROUGH THIS WEB SITE AND TYPING MY NAME IN THE BOX BELOW, I AM OFFERING MY DIGITIAL SIGNATURE IN LIEU OF MY HANDWRITTEN SIGNATURE. THE AUTHORIZING OFFICER IS CONSENTING TO APPLY FOR A WCRB WEB SERVICE IN ELECTRONIC FASHION. THE DIGITAL SIGNATURE CONTAINED WITHIN THIS APPLICATION IS ENFORCEABLE AND CANNOT BE DENIED LEGAL EFFECT PURSUANT TO WIS. STAT. 137.15(1).

Authorizing Officer Signature: