Workers’ Compensation Insurance Rating Bureau of California
®
eSCAD
®
Enrollment
Form 103 (Rev. 02/2019)
1221 Broadway, Suite 900 Voice 415.778.7021 escad@wcirb.com
Oakland, CA 94612 wcirb.com
Form AC103.19-0205
Instructions
Purpose of Form
This form is for use by WCIRB member insurers
(Insurers) only to begin the enrollment process for eSCAD,
the WCIRB’s online tool for Insurers to submit aggregate
financial data. The WCIRB will prepare the eSCAD Services
Agreement (eSCAD Agreement) based upon the information
provided in this form by the Insurer.
If an Insurer has a current eSCAD Agreement in place
this form does not need to be completed to add additional
users. To add users, contact your eSCAD company member
administrator. You may contact escad@wcirb.com to obtain
the name of your eSCAD company member administrator.
eSCAD Registration Requirements
This form must be completed in order to begin the eSCAD
enrollment process.
Section A — Insurer Information
List the name of the Insurer and the names of the insurance
companies that are part of the reporting together (Reporting
Group).
Section B — Insurer Primary Contact
The Insurer Primary Contact is the person with whom
the WCIRB will communicate regarding initial setup and
administration of eSCAD and data call issues.
Section C — eSCAD Member Administrator
The eSCAD Member Administrator is the person responsible
for administering eSCAD user accounts for the Insurer’s
Reporting Group.
Section D — Insurer Signatory
The Signatory must be an officer or attorney who has
the authority to legally bind the Insurer company and is
authorized to sign the eSCAD Agreement on the Insurer’s
behalf.
Section E — Insurer Legal Contact
The eSCAD Legal Contact is the person with whom the
WCIRB communicates for all issues related to the eSCAD
Agreement. This person must be an officer or attorney who
is authorized to accept legal notices on behalf of the Insurer
and Reporting Group.
Use of Third Parties
To authorize a third party entity to access the Insurer’s
data via WCIRB Connect, the Insurer must complete WCIRB
Form 902, Third Party Entity Registration, and then sign
a Consent to Use Third Party Entity and Agreement to
Indemnify (TPE Agreement). Form 902 can be accessed on
the WCIRB’s website wcirb.com.
Form Submission
This form may be completed electronically, printed or typed,
and emailed or mailed to the following:
Email escad@wcirb.com
Mail WCIRB Actuarial Department
1221 Broadway, Suite 900
Oakland, CA 94612
Questions/Additional Information
If you have questions about this form, call 415.778.7021 or
email escad@wcirb.com.
