Fillable 4764 Form 310 AnalyticsPortal Enrollment

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4764 Form 310 AnalyticsPortal Enrollment

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Workers’ Compensation Insurance Rating Bureau of California
®
Form L310.20-0108
AnalyticsPortal Enrollment
Form 310 (Rev. 01/2020)
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
Use of This Form
This form is for use by WCIRB member insurers
(Insurers) only to begin the process of enrolling in (1)
WCIRB AnalyticsPortal or (2) WCIRB AnalyticsPortal and
WCIRB Inquiry
®
. Upon receipt of this completed form, the
WCIRB
will prepare a WCIRB AnalyticsPortal Agreement
(Agreement) based on the information provided on this form.
AnalyticsPortal Enrollment
The WCIRB AnalyticsPortal provides access to executive
level benchmarking reports and data quality dashboards
WCIRB Inquiry provides powerful classification experience
and aggregate financial data query tools and detailed reports.
Submission of the completed form will initiate the enrollment
process for the Insurer.
Pricing
There is no charge for accessing the WCIRB AnalyticsPortal.
The fee for accessing WCIRB Inquiry is determined using the
most recent available pure premium written on California
workers’ compensation policies reported to the WCIRB
by the Insurer. The fees shown below are based upon a
calendar year and will be prorated for Insurers enrolling
during a calendar year.
Written Pure Premium Annual Fee
$0 to $250 million $8,000
More than $250 million $16,000
Required Information
Access to information in the WCIRB AnalyticsPortal and in
WCIRB Inquiry is impacted by how an Insurer reports data
to the WCIRB.
Insurers that are within the same NAIC group may enroll
under a single Agreement and access WCIRB Inquiry
reports for one, some, or all of the Insurers within the group;
however, due to the nature of how aggregate financial data
is reported to the WCIRB, some groupings may limit access
to some aggregate financial data and corresponding reports.
In addition, access to the reports and dashboards available
in the WCIRB AnalyticsPortal is restricted to authorized
individuals of the Insurer.
The WCIRB will work with Insurers to determine the
constituents of the grouping that is most appropriate while
safeguarding access to Insurers’ data.
• Primary Contact
The Insurer must designate a Primary Contact who has
the authority to act on behalf of the companies that are
subscribing to the WCIRB AnalyticsPortal
and WCIRB Inquiry.
• General System Administrator (GSA)
The Insurer must designate a General System
Administrator who will be responsible for establishing and
administering user accounts for the Insurer.
• Legal Contact
The Insurer must designate an officer or attorney affiliated
with the Insurer as the Legal Contact. The Legal Contact
must be authorized to accept legal notices.
• Insurer Signatory
Each Insurer within a group must have a Signatory to the
Agreement. The Signatory must be an officer or attorney
affiliated with the Insurer who is authorized to legally bind
the Insurer and who is authorized to sign the Agreement
on behalf of the Insurer.
Form Completion
This form may 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.
Instructions
Workers’ Compensation Insurance Rating Bureau of California
®
AnalyticsPortal Enrollment
Form 310 (Rev. 01/2020)
Form L310.20-0108
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
A. Insurer Information
Name of Insurer or Insurer Group NAIC Group Number (if known)
If enrolling an Insurer Group, list all Insurers included in this enrollment request:
B. Primary Contact
The Primary Contact should have the authority to act on behalf of all the insurers identified in Section A.
Name Title
Company Name
Address City State Zip
Telephone Email
C. General System Administrator (GSA)
The General System Administrator has the authority to administer users for all the insurers identified in Section A.
Name Title
Company Name
Address City State Zip
Telephone Email
Workers’ Compensation Insurance Rating Bureau of California
®
AnalyticsPortal Enrollment
Form 310 (Rev. 01/2020)
Form L310.20-0108
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
D. Legal Contact
The Legal Contact must be an officer or attorney affiliated with the Insurer or Insurer Group and who is authorized to accept
legal notices on behalf of all the insurers identified in Section A.
Name Title
Company Name
Address City State Zip
Telephone Email
E. Insurer Signatory
Each insurer identified in Section A above must have an Insurer Signatory who is (1) an officer or attorney affiliated with the
Insurer or Insurer Group, (2) authorized to legally bind the insurer, and (3) authorized to sign the WCIRB AnalyticsPortal
Agreement on behalf of the insurer. If the Insurer Signatory does not have authority to sign the Agreement on behalf of all the
insurers identified in Section A, multiple signatories are required.
Check this box if the Insurer Signatory is authorized to sign the Agreement on behalf of all the insurers identified in
Section A. If this box is not checked, Section G must be completed for each remaining insurer identified in Section A.
Name Title
Company Name
Address City State Zip
Telephone Email
F. WCIRB Inquiry and Third Party Access
To request Insurer access and/or Third Party Entity (TPE) access to WCIRB Inquiry, check the applicable box(es)
below. To authorize a TPE to access WCIRB Inquiry on the Insurer’s behalf, the Insurer must submit a completed Form 908,
Third Party Entity Registration Form — WCIRB Inquiry (Form 908) and sign a Consent to Use Third Party Entity and Agreement
to Indemnify — WCIRB Inquiry (TPE Inquiry Agreement) before any TPE will be given access to WCIRB Inquiry.
Request Insurer access to WCIRB Inquiry.
Request TPE Access to WCIRB Inquiry.
The Legal Contact, Primary Contact and Signatory information for the TPE Inquiry Agreement will be the same as provided
on this form.
Workers’ Compensation Insurance Rating Bureau of California
®
AnalyticsPortal Enrollment
Form 310 (Rev. 01/2020)
Form L310.20-0108
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
G. Additional Signatory(ies) (see Section E)
Each Insurer Signatory must be (1) an officer or attorney affiliated with the Insurer, (2) authorized to legally bind the Insurer,
and (3) authorized to sign the AnalyticsPortal Agreement on behalf of the Insurer.
Name Title
Company Name
Address City State Zip
Telephone Email
Name Title
Company Name
Address City State Zip
Telephone Email
Name Title
Company Name
Address City State Zip
Telephone Email
Name Title
Company Name
Address City State Zip
Telephone Email
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Completed 3 July 2020

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