Fillable 1223 Form 401 Coverage Search - Government Users 15-0122.indd

Fill Online, Printable, Fillable, Blank 1223 Form 401 Coverage Search - Government Users 15-0122.indd Form

Use Fill to complete blank online WCIRB CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

1223 Form 401 Coverage Search - Government Users 15-0122.indd

On average this form takes 40 minutes to complete

The 1223 Form 401 Coverage Search - Government Users 15-0122.indd form is 5 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 154 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your WCIRB California forms online.

BROWSE WCIRB CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Workers’ Compensation Insurance Rating Bureau of California
®
Request for Remote Access to Coverage Information
Form 401 (Rev. 7/2013)
Form IT401.13-0729
WCIRBCalifornia
®
Objective.Trusted.Integral.
1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 www.wcirb.com
Purpose of Form
Use this form to request User IDs and passwords for remote
access to the WCIRB’s online coverage information. You
may use this form to add new user accounts or delete user
accounts that are no longer needed.
Use of Form
This form is intended for use by the Authorized Contact of a
governmental agency that has entered into an MOU with the
WCIRB for remote access to coverage information. If you are
not the Authorized Contact of such a governmental agency,
please call WCIRB Customer Service for assistance.
Form Completion
This form can be completed electronically. You may also
complete this form manually and scan/email or fax it to the
WCIRB. Please print clearly.
The completed form may be sent to:
WCIRB California
1221 Broadway, Suite 900
Oakland, CA 94612
Attn: Contracts Administrator, Legal Department
contracts@wcirb.com
Incomplete forms will be returned and may result in a
delay. If you need additional information or assistance in
completing the form, please call WCIRB Customer Service.
To Add New User(s)
Complete Sections A and B. This form allows for the addition
of up to 10 new users. If you need to add more than 10
users, please submit a separate form. Note that the email
address for your users must be a work email address.
To Remove User(s)
Complete Sections A and C. This form allows for the deletion
of up to 6 users. If you need to delete more than 6 users,
please submit a separate form.
Form Processing
Upon receipt of this form, the WCIRB will add or remove
user accounts for the WCIRB online system. New users will
receive an email with a User ID, temporary password and
instructions for setting a new password.
Questions
Call WCIRB Customer Service toll free at 888. 229.2472
7:30 a.m.–5:00 p.m. PST.
Workers’ Compensation Insurance Rating Bureau of California
®
Request for Remote Access to Coverage Information
Form 401 (Rev. 7/2013)
Form IT401.13-0729
1 of 4
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 www.wcirb.com
Section A—Authorized Agency Contact
You must be the Authorized Contact of a governmental agency that has entered into a memorandum of understanding (MOU)
with the WCIRB for remote access to coverage information. If you are not the Authorized Contact of such a governmental
agency, please call WCIRB Customer Service for assistance.
First Name Last Name
Title
Governmental Agency Name
Division or Department
Street Address
City State Zip
Telephone Fax
Email
I affirm that I am authorized by the governmental agency referenced above to request User IDs and passwords for agency
employees.
Signature Date
click to sign
signature
click to edit
Workers’ Compensation Insurance Rating Bureau of California
®
Request for Remote Access to Coverage Information
Form 401 (Rev. 7/2013)
Form IT401.13-0729
2 of 4
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 www.wcirb.com
Section B—Add New User(s)
First Name Last Name Title
Governmental Agency Division or Department
Street Address
City State Zip
Telephone Email
First Name Last Name Title
Governmental Agency Division or Department
Street Address
City State Zip
Telephone Email
First Name Last Name Title
Governmental Agency Division or Department
Street Address
City State Zip
Telephone Email
First Name Last Name Title
Governmental Agency Division or Department
Street Address
City State Zip
Telephone Email
First Name Last Name Title
Governmental Agency Division or Department
Street Address
City State Zip
Telephone
Governmental Agency / Division or Department
Workers’ Compensation Insurance Rating Bureau of California
®
Request for Remote Access to Coverage Information
Form 401 (Rev. 7/2013)
Form IT401.13-0729
3 of 4
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 www.wcirb.com
Section B—Add New User(s)
First Name Last Name Title
Governmental Agency Division or Department
Street Address
City State Zip
Telephone Email
First Name Last Name Title
Governmental Agency Division or Department
Street Address
City State Zip
Telephone Email
First Name Last Name Title
Governmental Agency Division or Department
Street Address
City State Zip
Telephone Email
First Name Last Name Title
Governmental Agency Division or Department
Street Address
City State Zip
Telephone Email
First Name Last Name Title
Governmental Agency Division or Department
Street Address
City State Zip
Telephone
Governmental Agency / Division or Department
Workers’ Compensation Insurance Rating Bureau of California
®
Request for Remote Access to Coverage Information
Form 401 (Rev. 7/2013)
Form IT401.13-0729
4 of 4
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 www.wcirb.com
Section C—Delete Existing User(s)
First Name Last Name
Governmental Agency Division or Department
User ID (email address)
First Name Last Name
Governmental Agency Division or Department
User ID (email address)
First Name Last Name
Governmental Agency Division or Department
User ID (email address)
First Name Last Name
Governmental Agency Division or Department
User ID (email address)
First Name Last Name
Governmental Agency Division or Department
User ID (email address)
First Name Last Name
Governmental Agency Division or Department
User ID (email address)
Governmental Agency / Division or Department
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

1223 Form 401 Coverage Search - Government Users 15-0122.indd

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document