Workers’ Compensation Insurance Rating Bureau of California
®
Robotic Tool Registration — WCIRB Connect
®
Form 906 (08/2019)
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
Form LD906.082019
Instructions
Purpose of Form
This form should be used by WCIRB member insurers only
to request permission to use a Robotic Process Automation
Software Tool (Robotic Tool) on the WCIRB’s private
member website, WCIRB Connect. The WCIRB will use the
information provided in this form to prepare an Agreement
regarding the use of the Robotic Tool.
A Robotic Tool may be associated with only one insurer.
An Insurer must complete a separate form for each
Robotic Tool it wishes to use.
Robotic Tool Registration
Upon receipt of this completed form, the WCIRB will initiate
the registration process by reviewing the information
provided to ensure WCIRB access and technical
requirements are met.
Once the Agreement is signed, the setup process can
begin and the WCIRB will work with the designated Primary
Contact to create an Insurer Robotic Tool User Account.
Required Information
Insurer Information
The name of the Insurer requesting authorization to use a
Robotic Tool on Connect.
Primary Contact
The Primary Contact must be an employee of the Insurer with
whom the WCIRB will communicate regarding initial setup.
Legal Contact
The Legal Contact must be an officer or attorney who is
authorized to accept legal notices on behalf of the Insurer.
Insurer Signatory
The Insurer Signatory must be an officer or attorney who has
the authority to legally bind the company and is authorized to
sign the Agreement on the Insurer’s behalf.
Technical Contact
The Technical Contact must be a person in the Insurer’s
Information Technology Department who will interface
with the WCIRB’s IT Department. This person should have
a thorough understanding of the Insurer’s information
technology system.
Robotic Tool Information
Specifications
This section details the Access Requirements and Technical
Requirements that must be met before a Robotic Tool may be
used in WCIRB Connect.
IP Address
Provide the source IP address of the Robotic Tool.
Robotic Tool Source
Provide the source from which the Robotic Tool is acquired/
created. If the source is the Insurer’s in-house resources, this
must be indicated. If the source is a third party, the name of the
third party must be provided.
Robotic Tool Email
Provide the email address to use as the Bot ID account. This
email must have an insurer domain and be active before
the Agreement is signed. This email should not be an email
currently in use within WCIRB Connect as enrollment of a
duplicate email will cause errors during setup.
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.
