Fillable Form 10041 Form 804 (WCIRB California)

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Form 10041 Form 804 (WCIRB California)

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1221 Broadway, Suite 900 dqa@wcirb.com
Oakland, CA 94612 wcirb.com
Form DQA804.032020
Workers’ Compensation Insurance Rating Bureau of California
®
WCIRB Member Office and Contact Designation
Form 804 (Rev. 03/2020)
Instructions
Purpose of Form
This form is for WCIRB members to provide the WCIRB with
information on the locations of their Home Office, Policy
Issuing Office and Unit Statistical Reporting (USR) Office as
well as designated contacts within their company, or to notify
the WCIRB of updates to this information.
Form Submission
This form should be completed electronically and emailed to
the Data Quality Assurance office.
• For existing WCIRB members providing updated
office or contact information, please only complete the
applicable sections of this form.
• For new WCIRB members, please complete all
sections of this form.
Email: dqa@wcirb.com
Definitions
Home Office
The physical address of the insurer’s headquarters or main
office location.
Policy Issuing Office and Contact
The office where policies underwriting California workers’
compensation coverage are issued. Policy correspondence
and related information will be sent to this address. The
designated individual will be the primary contact for all
policy-related issues.
Financial and Billing Contact
The designated individual will be the WCIRB’s primary
contact for all financial matters and to whom all invoices for
products and services will be sent.
Unit Statistical Reporting (USR) Office and Contact
The office handling unit statistical reporting for the insurer.
USR correspondence and related information will be
forwarded to this office. The designated individual will be the
primary contact for all USR-related issues.
Aggregate Financial Data Reporting Contact
The designated individual will be the primary contact for
all aggregate financial data reporting and eSCAD-related
issues.
Data Submission Contact
The designated individual will be the WCIRB’s primary
contact for all policy and USR data submission matters.
Legal Contact
The designated individual will be the WCIRB’s primary
contact for all legal matters. The Legal Contact must be an
officer or attorney affiliated with the insurer, not a Third Party
Entity, who is authorized to accept legal notices on behalf of
the insurer.
Membership Proxy Information
The WCIRB holds an annual meeting to elect new committee
members and adopt changes to the WCIRB constitution.
A quorum of Regular members is required at this meeting.
(See WCIRB Constitution.) If a Regular member, please
designate a person to receive proxy and other annual
meeting information.
Workers’ Compensation Insurance Rating Bureau of California
®
WCIRB Member Office and Contact Designation
Form 804 (Rev. 03/2020)
1 of 3
Form DQA804.032020
1221 Broadway, Suite 900 dqa@wcirb.com
Oakland, CA 94612 wcirb.com
Home Office
Company Name NAIC Company Code NCCI Code
NAIC Group Name (if applicable) NAIC Group Code (if applicable)
Address City State Zip
Telephone General Company Email (The official company email to receive official notices and communications from the WCIRB)
Policy Issuing Office
Name of Office
Address City State Zip
Telephone
Policy Contact Add Contact Replace Contact*
Name Title
Company Name
Address City State Zip
Telephone Email
*If replacing a policy contact, please provide the name of the contact to be replaced and effective date of the change.
Name of Contact to be Replaced Effective Date of Change
Financial or Billing Contact Add Contact Replace Contact*
Name Title
Company Name
Address City State Zip
Telephone Email
*If replacing a financial or billing contact, please provide the name of the contact to be replaced and effective date of the change.
Name of Contact to be Replaced Effective Date of Change
Workers’ Compensation Insurance Rating Bureau of California
®
WCIRB Member Office and Contact Designation
Form 804 (Rev. 03/2020)
2 of 3
Form DQA804.032020
1221 Broadway, Suite 900 dqa@wcirb.com
Oakland, CA 94612 wcirb.com
Unit Statistical Reporting Office
Name of Office
Address City State Zip
Telephone
Unit Statistical Reporting Contact Add Contact Replace Contact*
Name Title
Company Name
Address City State Zip
Telephone Email
*If replacing a unit statistical reporting contact, please provide the name of the contact to be replaced and effective date of the change.
Name of Contact to be Replaced Effective Date of Change
Aggregate Financial Data Reporting Contact Add Contact Replace Contact*
Name Title
Company Name
Address City State Zip
Telephone Email
*If replacing an aggregate financial data reporting contact, please provide the name of the contact to be replaced and effective date of the change.
Name of Contact to be Replaced Effective Date of Change
Data Submission Contact Add Contact Replace Contact*
Name Title
Company Name
Address City State Zip
Telephone Email
*If replacing a data submission contact, please provide the name of the contact to be replaced and effective date of the change.
Name of Contact to be Replaced Effective Date of Change
Workers’ Compensation Insurance Rating Bureau of California
®
WCIRB Member Office and Contact Designation
Form 804 (Rev. 03/2020)
3 of 3
Form DQA804.032020
1221 Broadway, Suite 900 dqa@wcirb.com
Oakland, CA 94612 wcirb.com
Legal Contact Add Contact Replace Contact*
Name Title
Company Name
Address City State Zip
Telephone Email
*If replacing a legal contact, please provide the name of the contact to be replaced and effective date of the change.
Name of Contact to be Replaced Effective Date of Change
Membership Proxy Information (Regular members only)
Name Title
Company Name
Address City State Zip
Telephone Email
Contact Information of Individual Completing This Form
Name Title
Company Name
Telephone Email
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Form 10041 Form 804 (WCIRB California)

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Completed 15 July 2020

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