Workers’ Compensation Insurance Rating Bureau of California
®
Form FIA1101.18-0919
1221 Broadway, Suite 900 accountingdept@wcirb.com
Oakland, CA 94612 wcirb.com
New Member Application
Form 1101 (09/2018)
Purpose of Form
This form is used to apply for membership in the WCIRB.
Every insurer authorized to transact California workers’
compensation insurance and employers’ liability insurance
incidental thereto and written in connection therewith is
eligible for membership in the WCIRB.
Use of Form
This form is used by insurers who are applying to the California
Department of Insurance for a Certificate of Authority to
transact workers’ compensation insurance in California.
Section A — Insurer Information
Provide the name of Insurer and the following:
• Insurer Address
The Primary Address of the Insurer corporate office.
• Insurer Contact
The Contact is the person with whom the WCIRB will
communicate regarding the application process.
• NAIC #
Each Insurer is required to provide their NAIC #.
• NAIC Group Affiliation
Provide the NAIC Group Number and Name if applicable.
Section B — Billing Contact Information
Provide the name, address and contact information for which
invoices should be directed.
Section C — Officer Signatory Information
Provide the name, title and contact information for the Officer
of the Insurer responsible for signing the WCIRB Constitution
and By-Laws.
Section D — Membership Level
Select from the two types of Membership levels available.
Section E — Contact Information of Person
Submitting Application
Provide the name and contact information of the person
submitting the application to WCIRB.
Form Submission
This form may be completed electronically or manually. It
may be scanned and emailed or mailed:
EMAIL accountingdept@wcirb.com
MAIL WCIRB, Accounting
1221 Broadway, Suite 900
Oakland, CA 94612
Questions/Additional Information
Call the WCIRB Accounting Specialist, Member Services at
415.778.7089 between 8:00 AM to 4:30 PM.
Instructions