Fillable 125 Form 902 - Third Party Entity Registration

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125 Form 902 - Third Party Entity Registration

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Workers’ Compensation Insurance Rating Bureau of California
®
Third Party Entity Registration
Form 902 (Rev. 03/2019)
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
Form L902.19-0318
Instructions
About This Form
This form is for use by WCIRB member insurers (Insurers) only
to designate a Third Party Entity (TPE) to act on behalf of a specific
Insurer. Upon receipt of this completed form, the WCIRB will prepare
a Consent to Use Third Party Entity and Agreement to Indemnify (TPE
Agreement) based on the information provided.
Each Insurer must submit a separate registration form for each
TPE being authorized to act on its behalf. Sections A and B must
be completed on each form. The Insurer must also complete either
Section C, D, E, F, or any combination of these sections.
TPE Registration Requirements
A. Insurer Information
List the Company Name, Address, Primary Contact, Signatory, and
Legal Contact. The Primary Contact is the person with whom the
WCIRB will communicate regarding the registration process. The
Signatory must be an officer or attorney who has the authority to
legally bind the company and is authorized to sign the TPE Agreement
on the Insurer’s behalf. The Legal Contact is the person authorized to
accept legal notices on behalf of the Insurer and must be an officer of or
attorney affiliated with the Insurer.
The Primary Contact, Signatory, and Legal Contact must be
affiliated with the Insurer and not the TPE.
B. TPE Information
List the TPE’s name, address, Federal Employer Identification Number,
Primary Contact, and Systems/Technical Contact. The Primary
Contact is the person with whom the WCIRB will communicate with
as needed. The Systems/Technical Contact is the person with whom
WCIRB information technology staff will communicate with as needed.
C. Authorization for Information
The Insurer may authorize the TPE to submit the following to the
WCIRB: Policy data, Unit statistical data, Aggregate financial data,
Medical transaction data, Long Term Survey responses, Permanent
Disability, Workers’ Compensation Terrorism Policy Information
Survey responses, and/or policy forms for approval.
D. Authorization to Access WCIRB Connect™
Insurers with access to WCIRB Connect may authorize the TPE to
have one of the following four levels of access to the website:
Level 1 - Restricted Access - Policyholder Search
Level 2 - Restricted Access - Submitter
Level 3 - Restricted Access - BSI
Level 4 - Unrestricted Access - Insurer Level
By authorizing the TPE to have either Level 2, Level 3 or Level 4
Access, the Insurer’s System Administrator will have the ability to
authorize the TPE Authorized Users to respond to the Insurer’s work
queue items in Connect. If Level 2 – Restricted Access – Submitter
is authorized, the TPE will only be able to view and respond to
work queue items for the data submitted by that TPE. If Level 3 –
Restricted Access –BSI is authorized, the TPE will only be able to
view and respond to work queue items that relate to policy and/or unit
statistical data reported with the Business Segment Identifier (BSI)
assigned to that TPE. If Level 4 – Unrestricted Access – Insurer Level
is authorized, the TPE will be able to view and respond to all work
queue items for that Insurer. Additional details about what each level
of access includes are provided in Section D in the form below.
E. Authorization to Request and Receive Data via WCIRB
X-Mods and More™
Insurers with access to WCIRB X-Mods and More may authorize the
TPE to request and receive data via WCIRB X-Mods and More (API
Services). API Services authorization allows the TPE to request and
receive risk-level data including 10 years of experience modifications
with corresponding rating effective year, reported policyholder names
and addresses, and WCIRB assigned and reported classifications.
The TPE can also receive rating effective dates if the authorizing
Insurer is the insurer of record and pursuant to the TPE’s level of
access in WCIRB Connect. Additional details about what each level
of access includes is provided is Section E in the form below.
F. Authorization to Request and Receive Coverage
Information
The Insurer may authorize the TPE to request and receive coverage
information relating to a pending workers’ compensation claim.
Form Completion
This form can be completed electronically, printed or typed, and
emailed or mailed to the following:
Email contracts@wcirb.com
Mail WCIRB Legal Department
1221 Broadway, Suite 900
Oakland, CA 94612
If you have questions about this form, contact the WCIRB Contract
Administrator at 415.778.7241 or email
contracts@wcirb.com.
Workers’ Compensation Insurance Rating Bureau of California
®
Third Party Entity Registration
Form 902 (Rev. 03/2019)
1 of 4
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
Form L902.19-0318
A. Insurer Information
Name of Insurer
Address City State Zip
Insurer Primary Contact
The Insurer Primary Contact is the person with whom the WCIRB will communicate regarding the registration process and must
be affiliated with the Insurer, not the TPE.
Primary Contact Name Title
Primary Contact Address City State Zip
Telephone Email (required)
Insurer Signatory
The Insurer Signatory must be an officer or attorney affiliated with the Insurer, not the TPE, who is authorized to legally bind the
company and is authorized to sign the TPE Agreement on behalf of the Insurer.
Signatory Name Title
Signatory Address City State Zip
Telephone Email (required)
Insurer Legal Contact
The Insurer Legal Contact must be an officer or attorney affiliated with the Insurer, not the TPE, who is authorized to accept
legal notices on behalf of the Insurer.
Legal Contact Name Title
Legal Contact Address City State Zip
Telephone Email (required)
INTENTIONALLY LEFT BLANK
Workers’ Compensation Insurance Rating Bureau of California
®
Third Party Entity Registration
Form 902 (Rev. 03/2019)
2 of 4
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
Form L902.19-0318
B. TPE Information
Insurers must submit a separate registration form for each TPE designated to act on its behalf.
Company Name
Address City State Zip
Federal Employer Identification Number (FEIN)
TPE Primary Contact
The TPE Primary Contact is the person with whom the WCIRB will communicate regarding initial setup and administration of
TPE services.
Primary Contact Name Title
Primary Contact Address City State Zip
Telephone Email (required)
TPE Systems/Technical Contact
The TPE Systems/Technical Contact is the person with whom WCIRB information technology staff will communicate during the
TPE setup and thereafter as needed.
Systems/Technical Contact Name Title
Systems/Technical Contact Address City State Zip
Telephone Email (required)
C. Authorization for TPE to Submit Information
To authorize the TPE to submit data, policy forms or respond to survey requests on the Insurer’s behalf, indicate by checking the
appropriate box(es) below. This authorization allows the WCIRB to communicate with the TPE regarding the submission by any
means including telephone, email or other electronic means, fax or mail.
Policy Data
Unit Statistical Data (All Report Levels and Corrections)
Aggregate Financial Data
Medical Transaction Data
Long-Term Loss Development Survey Responses
Permanent Disability Survey Responses
Workers’ Compensation Terrorism Policy Survey Responses
Policy Forms for Approval (Policy Forms, Endorsement Forms, Ancillary Agreements and Notice Forms)
Workers’ Compensation Insurance Rating Bureau of California
®
Third Party Entity Registration
Form 902 (Rev. 03/2019)
3 of 4
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
Form L902.19-0318
D. Authorization for Access to WCIRB Connect
®
To authorize the TPE to access WCIRB Connect on the Insurer’s behalf, indicate by checking the appropriate box the specific
level of access the Insurer authorizes. This authorization allows the WCIRB to communicate with the TPE regarding the accessed
information or action taken in the work queue by any means including telephone, email or other electronic means, fax or mail.
The Insurer’s System Administrator determines the specific roles assigned to each TPE Authorized User within each access
level. All levels of access allow the TPE to search for any policyholder by name, FEIN or Bureau Number, view experience
modifications and WCIRB assigned classifications, subscribe to X-Mod Direct and request a Risk Summary Report.
Level 1 Access - Restricted: Policyholder Search
This level of access also allows TPE Authorized Users, if authorized in Connect by the Insurer’s System Administrator, to
view all the Insurer’s policyholders’ rate sheets and inspection reports. TPE Authorized Users will not be able to respond to
Insurer work queue items.
Level 2 Access - Restricted: Submitter
This level of access also allows TPE Authorized Users, if authorized in Connect by the Insurer’s System Administrator, to (1)
respond to work queue items relating to the Insurer’s policy and unit statistical data if the TPE is identified as the submitter
on the Electronic Transmission Record (ETR) for the data, (2) view rate sheets, inspection reports and detailed policy and
unit statistical data for policies submitted by the TPE, (3) search for policy audit and unit statistical audit letters for policies
submitted by the TPE, (4) access Submission Manager to view submission reports relating to submissions made by the
TPE and (5) submit Test Audit data if the TPE submitted the policy at issue.
Level 3 Access - Restricted: BSI
This level of access also allows TPE Authorized Users, if authorized in Connect by the Insurer’s System Administrator, to
(1) respond to Insurer work queue items in Connect for policy work queue items that relate to policy data submitted with the
assigned BSI and/or unit statistical data work queue items that relate to unit statistical data submitted with the assigned
BSI, (2) view rate sheets if the rate sheet is related to policy and/or unit statistical data submitted with the assigned BSI,
(3) view inspection reports if the inspection report relates to policy and/or unit statistical data submitted with the assigned
BSI, (4) view detailed policy data submitted with the assigned BSI, (5) view detailed unit statistical data submitted with
the assigned BSI, (6) search for policy and/or unit statistical audit letters for the related policy and/or unit statistical data
submitted with the assigned BSI, relating to the Insurer and (7) submit Test Audit data if the policy data has been submitted
with the assigned BSI.
Check here to allow all BSI TPE Authorized Users to access Submission Manager to view all submission reports
relating to the Insurer.
Level 4 Access - Unrestricted: Insurer Level
This level of access also allows TPE Authorized Users, if authorized in Connect by the Insurer’s System Administrator, to
(1) respond to any Insurer work queue items in Connect, (2) view all of the Insurer’s data that the Insurer can view for all of
the Insurer’s policyholders, regardless of whether the TPE submitted the data, (3) view all information that the Insurer can
view including Scheduled Reports, (4) search for policy audit and unit statistical audit letters for the Insurer; (5) submit and
approve requests submitted by agents or brokers for change in ownership and/or combinability of entities, and (6) access
Submission Manager to view all submission reports when provided access to policy or unit statistical data and (7) submit
Test Audit data.
Continue to page 4 and complete Sections E and F, if applicable.
Workers’ Compensation Insurance Rating Bureau of California
®
Third Party Entity Registration
Form 902 (Rev. 03/2019)
4 of 4
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
Form L902.19-0318
E. Request and Receive Data via WCIRB X-Mods and More™
To authorize the TPE to request and receive data via WCIRB X-Mods and More on the Insurer’s behalf, indicate by checking
the box below. This authorization allows the WCIRB to communicate with the TPE regarding the accessed data by any means
including telephone, email or other electronic means, fax or mail.
Request and Receive X-Mods and More
This authorizes the TPE to request data by Bureau Number or FEIN and receive data by Bureau Number including
policyholder name, policyholder address, policyholder FEINs, risk ID number, state code, rating effective year, rating issue
date, rating type code, WCIRB assigned classification codes including the date assigned, classification code submitted
by insurer and the classification with the highest exposure for that Bureau Number. The TPE will have access to rating
effective dates if the Authorizing Insurer is the insurer of record and pursuant to the TPE’s level of access in WCIRB
Connect as follows: If the TPE has Level 2 – Restricted Access - Submitter, the TPE may receive rating effective dates if
the TPE is the submitter on the policy or unit statistical submission. If the TPE has Level 1 – Restricted Access Policyholder
Search or Level 4 – Unrestricted Access – Insurer Level, the TPE may receive rating effective dates for all policies for which
the Insurer is the insurer of record. If the TPE has Level 3 – Restricted Access – BSI, the TPE may receive rating effective
dates if the TPE is associated with the BSI on the policy or unit statistical submission.
If X-Mods and More is selected, provide the TPE IP Address:
F. Authorization to Request and Receive Coverage Information
To authorize the TPE to request and receive coverage information relating to a pending workers’ compensation claim on
the Insurer’s behalf, indicate by checking the box below. This authorization allows the WCIRB to communicate with the TPE
regarding the request and information provided by any means including telephone, email or other electronic means, fax or mail.
Request and Receive Coverage Information (relating to a pending workers’ compensation claim)
INTENTIONALLY LEFT BLANK
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Completed 3 July 2020

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