Workers’ Compensation Insurance Rating Bureau of California
®
Data Product Order
Form 805 (Rev. 12/2019)
1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 wcirb.com
Form CS805.122019
All products and services are prepared by the WCIRB in the normal course of business
pursuant to the regulations of the California Department of Insurance or for the benefit of
the WCIRB’s members. The WCIRB has made reasonable efforts to ensure the accuracy
of the products and services.
You must make an independent assessment regarding the use of all WCIRB products and
services based upon your particular facts and circumstances. The WCIRB cannot make
such an assessment and shall not be liable for any damages, of any kind, whether direct,
indirect, incidental, punitive or consequential, arising from the use, inability to use, or
reliance upon WCIRB products and services
Instructions
Purpose of Form
Use this form to order WCIRB statistical data products on the
WCIRB website, wcirb.com, as well as custom data products.
Ordering Data Products
Standard Data Products
Consult wcirb.com for the product number, description and
price and enter in section E of this form.
Custom Data Products
Call the WCIRB Contact Center to request custom data
products. The Contact Center will provide a description to
enter in section E. Enter AC9000A as the product number.
Leave the Price Not to Exceed column blank. Upon receipt of
the completed form, the WCIRB Contact Center will advise
regarding the Price Not to Exceed.
If ordering one or more custom data products as well as
statistical data products listed on wcirb.com, use a separate
Form 805 for the custom data product(s) requested. Each
form must be fully completed and signed.
Statement of Use and Data Sharing
In order to process the order, a statement regarding the
business use of the data product is required in section C.
An indication of whether the data will be shared with a third
party and, if so, the name and contact information of the third
party must be provided in section D.
Approval
The signature of an authorized individual in section F
approving the order, as listed, is required prior to preparation
of the License Agreement and subsequent production of the
data product.
License Agreement
After receipt of the signed order, a License Agreement is
prepared and sent for signature through DocuSign. The
signed License Agreement must be received before the
WCIRB will produce or deliver the data product.
Payment Method
The WCIRB must receive payment before processing the
order. Indicate the payment method and corresponding
authorization information in section B.
• Direct billing is available for WCIRB member insurers.
• The WCIRB accepts Visa
®
and Mastercard
®
or ACH.
Authorize.Net will email an electronic invoice to the
requester on behalf of WCIRB California and process the
credit card or ACH payment.
Product Delivery
The WCIRB delivery and handling (D/H) charge is
applicable to all orders. Refer to the chart below and add the
appropriate amount for your order. The delivery charge is per
unit of product; for example, if you order 5 units of the same
product or 1 unit each of 5 different products, the total D/H
charge is five times the unit charge.
Delivery Method D/H Fee
Electronically $5 per unit
Form Submission
This form can be completed electronically or printed out
and completed on hard copy. Electronic signatures are
acceptable when a signature is required. This form may be
emailed or mailed.
Email customerservice@wcirb.com
Mail WCIRB California
Attention: Contact Center
1221 Broadway, Suite 900
Oakland, CA 94612
Questions/Additional Information
Call the WCIRB Contact Center toll free:
888. CA WCIRB (229.2472), 7:30 AM – 4:45 PM PT
