This form is for use by WCRB carrier members only

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.)

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

Please contact wcrbwebmaster@wcrb.org for any questions regarding this form.


ALL FIELDS ARE REQUIRED

Web Service Type

Selected service type:

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:   Organization Name:  

Carrier ID: Note: The 5 digit bureau membership Carrier ID can be found in Exhibit 1 of the most recent WCRB Annual Report. This is not your NAIC Carrier Code.

Mailing Address (Street or PO Box):  

City:   State: 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: