Workers’ Compensation Insurance Rating Bureau of California
®
Policyholder Product Order
Form 801 (Rev. 12/2019)
1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 wcirb.com
Form CS801.122019
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.
Purpose of Form
Use this form to order Experience Rating Worksheets,
Classification Inspection Reports and Unit Statistical Reports
for a specific policyholder. The WCIRB provides these data
products to the policyholder or the policyholder’s insurer of
record; other parties may also obtain these data products if
authorized by the policyholder.
Insurers and their authorized third parties as well as agents
and brokers who have access to WCIRB Connect
®
can
request policyholder authorization to access Experience
Rating Worksheets and Classification Inspection Reports
directly via WCIRB Connect free of charge.
If You Are the Policyholder
• In section A, check the box “I am the policyholder”.
• Complete all sections of this form except section F.
A signature is required in section B.
If You Are the Insurer of Record
• In section A, check the box “I am the insurer of record
(according to the WCIRB’s records)”.
• Complete all sections of this form except section F.
If You Are Anyone Other Than the Policyholder or
Insurer of Record
• In section A, check the appropriate box.
• Complete all sections of the form, including section F;
otherwise, the WCIRB will not be able to process the order.
Payment Method
The WCIRB must receive payment before processing the
order. Indicate the payment method and corresponding
authorization information in section C.
• 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
The WCIRB delivery and handling (D/H) charge is applicable
to all product copies, including special delivery requests.
Refer to the chart below and add the appropriate amount for
your order. The delivery charge is per unit of product based
on delivery method; for example, if you order 5 units of the
same product or 1 unit each of 5 different products and
select the same delivery method, the total D/H charge is five
times the unit charge for that delivery method.
Delivery Method D/H Fee
Electronically $5 per unit
By Mail $15 per unit
For products delivered by mail, the following shipping
methods are available.
Standard
• Product orders provided in hard copy are mailed or
shipped ground.
• As mailing may be through UPS, a street address and
phone number must be provided.
Next Day Air Shipping
Next day air shipping is billed directly to the ordering
organization by the shipper.
• Complete the Shipper and Account Number fields.
• FedEx and UPS are recommended. For other shippers,
contact the WCIRB Contact Center.
• Specify the delivery speed.
Sales Tax
• Include 9.25 percent sales tax for all orders mailed to
California addresses. Products received via electronic
delivery are not subject to sales tax.
Form Submission
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 customerservice@wcirb.com
Mail WCIRB California
Attention: Contact Center
1221 Broadway, Suite 900
Oakland, CA 94612
Questions/Additional Information
Call the WCIRB Contact Center toll free:
888. CA WCIRB (229.2472), 7:30 AM – 4:45 PM PT
Instructions
