Fillable Form 1246 Form 205, Experience Modification Subscription (WCIRB California)

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Form 1246 Form 205, Experience Modification Subscription (WCIRB California)

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Workers’ Compensation Insurance Rating Bureau of California
®
Experience Modification Subscription
Form 205 (Rev. 11/2019)
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
Form L205.15-112019
Instructions
Purpose of Form
WCIRB member insurers (Insurers) and registered Advisory
Organizations in good standing with the California Department
of Insurance (CDI) can use this form to subscribe to the
Experience Modification Subscription product.
See California Insurance Code Sections 11750.1(e) and 11753
for information about Advisory Organizations. To become a
registered Advisory Organization, contact the CDI directly.
Ordering Process
• Upon receipt of this form, the WCIRB will verify eligibility
for the product. For Advisory Organizations, the WCIRB
will contact the CDI.
• Once eligibility is verified, an invoice for the order will be
generated and an Indemnification Agreement will be sent
to the signatory(ies) designated in section G.
• For Insurers, if experience modification data for more
than one company in the same NAIC group is requested
in section C, the signatory(ies) designated in section G
signing the Indemnification Agreement must have the
authority to sign the contract on behalf of each company.
• Upon receipt of the signed Agreement and payment, the
WCIRB will contact your designated Technical Contact in
section E to begin the setup process.
Price
$2,500 per year, prorated to the nearest month, and billed on
an annual basis. Payment is due in advance of service. No
refunds will be issued upon cancellation.
Payment Method
The WCIRB must receive payment before processing the
order. Indicate the payment method and corresponding
authorization information in section F.
• 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
This product is delivered electronically. See product
documentation, Experience Modification Subscription
#DP2010, for additional information.
Form Completion
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 contracts@wcirb.com
Mail WCIRB California
Attention: WCIRB Legal
1221 Broadway, Suite 900
Oakland, CA 94612
Questions/Additional Information
Call the WCIRB Contract Administrator at 415.778.7241 or
email contracts@wcirb.com.
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.
Workers’ Compensation Insurance Rating Bureau of California
®
Experience Modification Subscription
Form 205 (Rev. 11/2019)
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
Form L205.15-112019
1 of 3
A. Company Type Insurance Company (#DP2010) Advisory Organization (#DP2010A)
B. Primary Contact
Name Title
Company
Address (No P.O. Boxes) City State Zip
Telephone Email
C. Insurer Information (skip for Advisory Organization)
Insurers may elect to receive experience rating information for their own company or for one or more additional companies
within their NAIC group. If requesting experience rating data for more than one company in the same NAIC group, the Legal
Contact named in section D must have the authority to accept notice on behalf of each company in the designated group.
Please list the company(ies) in the box below.
D. Legal Contact
The Legal Contact is a corporate officer or attorney of the Insurer or Advisory Organization who is authorized to accept legal
notices on behalf of the Insurer or Advisory Organization.
Same as Primary Contact in section B
Name Title
Company Name
Address (No P.O. Boxes) City State Zip
Telephone Email
Workers’ Compensation Insurance Rating Bureau of California
®
Experience Modification Subscription
Form 205 (Rev. 11/2019)
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
Form L205.15-112019
2 of 3
E. Technical Contact
The Technical Contact is an employee of the Insurer or Advisory Organization in the Information Technology Department who
will be responsible for downloading and processing the file(s) and who has knowledge of the Insurer’s or Advisory Organization’s
information technology capabilities.
Name Title
Telephone Email
F. Payment Method
1. WCIRB Member Insurers Billing
I am authorized by the Insurer named in section B to request products. I understand that my company will be billed for
the products ordered by this form.
Authorized by Signature
Title Date
2. Payment by Credit Card or ACH (see Instructions)
Please provide the following:
Name on Card Email
Do not enter any credit card number onto this form. Credit card payment will be processed directly via Authorize.Net.
G. Signatory(ies)
The Signatory must be an officer or attorney affiliated with the Insurer or Advisory Organization and who is authorized to sign
the Agreement on behalf of the Insurer or Advisory Organization.
For Insurers, each insurer identified in section C must have an Insurer Signatory who is (1) an officer or attorney affiliated with the
Insurer, (2) authorized to legally bind the Insurer, and (3) authorized to sign the Indemnification 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 C, multiple
signatories are required.
Check this box if one Insurer Signatory is authorized to sign the Agreement on behalf of all the insurers identified in section C.
If this box is not checked, please provide additional signatory(ies) for the remaining insurer(s) on the next page.
Name Title
Company Name
Address (No P.O. Boxes) City State Zip
Telephone Email
Workers’ Compensation Insurance Rating Bureau of California
®
Experience Modification Subscription
Form 205 (Rev. 11/2019)
1221 Broadway, Suite 900 Voice 415.778.7241 contracts@wcirb.com
Oakland, CA 94612 wcirb.com
Form L205.15-112019
3 of 3
Please provide additional signatory(ies) below if the box in section G on the prior page is not checked.
Name Title
Company Name
Address (No P.O. Boxes) City State Zip
Telephone Email
Name Title
Company Name
Address (No P.O. Boxes) City State Zip
Telephone Email
Name Title
Company Name
Address (No P.O. Boxes) City State Zip
Telephone Email
Name Title
Company Name
Address (No P.O. Boxes) City State Zip
Telephone Email
Name Title
Company Name
Address (No P.O. Boxes) City State Zip
Telephone Email
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Form 1246 Form 205, Experience Modification Subscription (WCIRB California)

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Completed 15 July 2020

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