Fillable Self- Insured Data ( Form 701) (WCIRB California)

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Self- Insured Data ( Form 701) (WCIRB California)

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Workers’ Compensation Insurance Rating Bureau of California
®
Request to Use California Self-Insured Data for Experience Rating Purposes
Form 701 (Rev. 01/2018)
Form RS701.18-0101
1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 wcirb.com
Instructions
Purpose of Form
This form is for use when requesting that self-insured data
be used to promulgate an experience modification for an
insured employer. Employer, as used in this form, means a
single entity or two or more entities that are combinable for
experience rating purposes in accordance with Section IV,
Rule 2, of the California Workers’ Compensation Experience
Rating Plan—1995 (ERP).
Use of Form
This form must be submitted by the insurer providing coverage
for the period the proposed experience modification will be in
effect. Only self-insured data pertaining to the employer’s self-
insured California operations is eligible for use in experience
rating.
Requesting insurers submitting self-insured data
electronically in WCSTAT format need only complete
Sections A through E of this form.
Requesting insurers not submitting self-insured data
electronically in WCSTAT format must complete Sections A
through H of this form, with a separate Section G – Report
of Payroll and Section H – Report of Losses completed for
each reporting period.
Submission and Review of Self-Insured Data
All self-insured data developed during the applicable
experience period must be submitted. An experience
modification will not be promulgated with partial self-insured
data. The requesting insurer is strongly encouraged to
submit the self-insured data electronically in a WCSTAT
format consistent with that used to submit unit statistical data
on insured policies; otherwise, a $500 processing fee will be
charged for each request.
The self-insured data will be subject to the same rigorous
validation that applies to all unit statistical data reported
in accordance with the rules set forth in Part 4, Unit
Statistical Reporting Requirements, of the California
Workers’ Compensation Uniform Statistical Reporting
Plan—1995 (USRP). Self-insured data that is determined
to be acceptable will be eligible for use in experience rating.
If the prior valuation of self-insured data contained open
claims, or if previously reported closed claims were
subsequently reopened and/or revalued with different
incurred indemnity and/or incurred medical amounts, or
if one or more new claims were subsequently reported, a
separate request as well as the subsequent valuation of self-
insured claims must be submitted by the insurer providing
coverage for the period the proposed experience modification
using this subsequent valuation of claims will be in effect. The
regulations and procedures concerning the submission
and use of California self-insured data for experience
rating purposes are found in Section III, Rule 5, of the ERP.
The ERP and USRP are available on the WCIRB’s website
(wcirb.com).
Additional Information Required to be Submitted
with this Form
Applicable loss reports; subrogation, joint coverage, partially
fraudulent and compromised death claims must be identified
and the total gross incurred amount as defined in the USRP
must be provided for each such claim.
Form Completion
• This form can be completed electronically; if completed
manually, please print clearly.
• Authorized representatives from both the insurer and
employer must sign this form to verify the completeness
and accuracy of the information stated in the form and
the self-insured data that will be submitted to the WCIRB.
Insurance brokers/agents may not sign this form on behalf
of the employer or insurer.
• Failure to complete all sections of the form and provide all
required information may delay or prevent the request from
being processed.
Form Submission
Mail, fax or e-mail this completed form, including the signatures of
the authorized employer and insurer representative, to the WCIRB:
WCIRB Customer Service
WCIRB California
1221 Broadway, Suite 900
Oakland, CA 94612
415.778.7272 (fax)
customerservice@wcirb.com
Questions
Call WCIRB Customer Service toll free
888.CA.WCIRB (229.2472)
7:30 AM – 4:45 PM PST
Workers’ Compensation Insurance Rating Bureau of California
®
Request to Use California Self-Insured Data for Experience Rating Purposes
Form 701 (Rev. 01/2018)
Form RS701.18-0101
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 wcirb.com
Section A — Employer Information
Name of Employer (List the primary insured business name) Employer Bureau Number (If available)
List all other business names, including all DBAs.
Name of Insurer (For the policy covering the period during which the experience modification will be in effect)
Policy Number (For the period during which the experience modification will be in effect) Policy Period
Proposed Rating Date (Set by the new policy inception date unless otherwise prescribed by the ERP)
Name of Insurer (For the policy covering the period immediately preceding the period of self-insurance)
Policy Number (For the period immediately preceding the period of self-insurance) Policy Period
Section B — California Locations
List the address of each California location insured under the policy that covers the period during which the experience
modification will be in effect and provide a description of the operations conducted at each location. Only self-insured data
developed in connection with the employer’s California operations can be used to compute an experience modification. Any
change in operations resulting in a reclassification of operations during the five (5) years preceding the effective date of the
requested experience modification must be explained in writing.
Physical Address (No P.O. Boxes) Description of Operations
Section C — Ownership Information
If the employer’s business has undergone a change in ownership, as defined in the ERP, during the last five (5) years, a notification
of change in ownership and/or combinability of entities must be submitted to the WCIRB. Please go to WCIRB Connect
®
to submit
ownership information, visit the WCIRB’s website (wcirb.com), or contact WCIRB Customer Service to obtain more information.
Indicate by checking the appropriate box below whether there have been any changes in ownership during the last five (5) years.
Ownership changes have occurred during the last five (5) years. I have submitted a notification of change in ownership and/or
combinability of entities for each ownership change that has occurred during the last five (5) years.
No ownership changes have occurred during the last five (5) years.
1
Workers’ Compensation Insurance Rating Bureau of California
®
Request to Use California Self-Insured Data for Experience Rating Purposes
Form 701 (Rev. 01/2018)
Form RS701.18-0101
2
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 wcirb.com
Section D — Affidavit of the Employer
I certify under penalty of perjury under the laws of the State of California that the following statements are true and correct:
• I am authorized to complete this form on behalf of the employer identified in Section A of this form (The Employer);
• The information provided in this form is true and correct to the best of my knowledge; and
• All payroll and loss information provided to Insurer is an accurate and complete representation of the self-insured payroll and loss
data developed in connection with the operations that are currently insured under the policy identified in Section A of this form.
Name of Employer
Name of Employer’s Authorized Signatory (Please print or type)
Signature of Employer’s Authorized Signatory (Brokers or agents cannot sign on behalf of the employer)
Title Date
Section E — Insurer’s Verification of Self-Insured Data
I verify that:
• I am authorized to complete this form on behalf of the Insurance Company submitting this request (Insurer);
• The information provided in this form is true and correct to the best of my knowledge; and
• I understand and agree that Insurer is responsible for accurately submitting all of The Employer’s self-insured payroll and loss
data developed during the experience period in accordance with the rules of the USRP.
Name of Insurer
Name of Insurer’s Authorized Signatory (Please Print or Type)
Signature of Insurer’s Authorized Signatory (Brokers or Agents cannot Sign on Behalf of the Insurer)
Title Date
E-mail Address Phone Number
Workers’ Compensation Insurance Rating Bureau of California
®
Request to Use California Self-Insured Data for Experience Rating Purposes
Form 701 (Rev. 01/2018)
Form RS701.18-0101
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 wcirb.com
Please number Section G — Report of Payroll and Section H — Report of Losses Pages
Sections F through H Must Be Completed If Not Submitting Self-Insured Data Electronically in
WCSTAT Format.
Section F — Payment Method
WCIRB Member Insurer Billing
Authorized by (Print Name) Signature
Title Date
Member Company
Address
City State Zip
Instructions and Notes for Section G — Report of Payroll and Section H — Report of Losses
There are three two-page sets (one page for Payroll and one page for Losses) in this form.
1. List the employer’s name and Bureau Number at the top of each sheet.
2. Indicate the Reporting Period on each Section G and Section H sheet and the Loss Valuation Date on each Section H sheet.
3. If you have two or more Reporting Periods, always begin the next Reporting Period on a new set of pages, even if the previous
sheets are not full.
4. If Report of Losses for a reporting period requires multiple sheets, please place required totals on the last sheet for that
reporting period only.
5. If there is insufficient space for the data, download another copy of this form from the WCIRB website, wcirb.com, or copy
the applicable pages.
6. Please sequentially number all pages submitted. Start numbering the Payroll and Losses pages from Page 4, the page
after this one. There is a space at the bottom of each page for this purpose.
NOTES:
1. Payroll and loss data must be submitted as if the employer had been covered by policies incepting on the same month and
day as the Rating Date. If the inception date (month and day) of the self-insured period does not coincide with the Rating
Date, report the actual inception date. The expiration date of the first reporting period must coincide with the Rating Date.
The inception date of each reporting period thereafter must coincide with the Rating Date. If the expiration date of the last
reporting period does not coincide with the Rating Date, report the actual expiration date.
2. Subrogation, joint coverage, partially fraudulent and compromised death claims must be identified and the total gross incurred
amount as defined in the USRP must be provided for each such claim.
3. Catastrophe claims must be identified and reported as defined in the USRP in the Cat. No. column.
Workers’ Compensation Insurance Rating Bureau of California
®
Request to Use California Self-Insured Data for Experience Rating Purposes
Form 701 (Rev. 01/2018)
Form RS701.18-0101
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 wcirb.com
Please number Section G — Report of Payroll and Section H — Report of Losses Pages
Sections F through H Must Be Completed If Not Submitting Self-Insured Data Electronically in
WCSTAT Format.
Name of Employer Employer Bureau Number (If Available)
Section G — Report of Payroll
1. Indicate the Reporting Period (Inception to Expiration Date)
Reporting Period (Inception to Expiration Date) See NOTE 1 of Instructions and Notes for Section G – Report of Payroll and Section H – Report of Losses.
2. Payroll (Not required for subsequent reports)
Classification Code Payroll
Classification Code Payroll
Workers’ Compensation Insurance Rating Bureau of California
®
Request to Use California Self-Insured Data for Experience Rating Purposes
Form 701 (Rev. 01/2018)
Form RS701.18-0101
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 wcirb.com
Please number Section G — Report of Payroll and Section H — Report of Losses Pages
Sections F through H Must Be Completed If Not Submitting Self-Insured Data Electronically in
WCSTAT Format.
Name of Employer Employer Bureau Number (If Available)
Section H — Report of Losses (Value claims in accordance with USRP, Part 4, and attach loss reports.)
1. Indicate the Reporting Period (Inception to Expiration Date) Indicate the Loss Valuation Date (Month/Year)
Reporting Period (Inception to Expiration Date) Month/Year
If there are no losses for this period, check this box to confirm that no losses were incurred during this reporting period and provide the
corresponding loss report.
2. Losses (See NOTE 2 of Instructions and Notes for Section G – Report of Payroll and Section H – Report of Losses.)
Claim Number
Accident
Date
MM/DD/YYYY
Injury
Type
(U S RP,
Part 4)
Classification
Code
Incurred Losses
Type of
Recovery
(USRP, Part 4)
Total Gross
Incurred Amt
(USRP, Part 4)
Type of
Settlement
(USRP, Part 4)
Fraudulent
Claim Code
(USRP, Part 4)
Open
(O)/
Closed
(F)
Cat.
No.Indemnity Medical
Fill in totals on the last page of each reporting period. Totals
Workers’ Compensation Insurance Rating Bureau of California
®
Request to Use California Self-Insured Data for Experience Rating Purposes
Form 701 (Rev. 01/2018)
Form RS701.18-0101
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 wcirb.com
Please number Section G — Report of Payroll and Section H — Report of Losses Pages
Sections F through H Must Be Completed If Not Submitting Self-Insured Data Electronically in
WCSTAT Format.
Name of Employer Employer Bureau Number (If Available)
Section G — Report of Payroll
1. Indicate the Reporting Period (Inception to Expiration Date)
Reporting Period (Inception to Expiration Date) See NOTE 1 of Instructions and Notes for Section G – Report of Payroll and Section H – Report of Losses.
2. Payroll (Not required for subsequent reports)
Classification Code Payroll
Classification Code Payroll
Workers’ Compensation Insurance Rating Bureau of California
®
Request to Use California Self-Insured Data for Experience Rating Purposes
Form 701 (Rev. 01/2018)
Form RS701.18-0101
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 wcirb.com
Please number Section G — Report of Payroll and Section H — Report of Losses Pages
Sections F through H Must Be Completed If Not Submitting Self-Insured Data Electronically in
WCSTAT Format.
Name of Employer Employer Bureau Number (If Available)
Section H — Report of Losses (Value claims in accordance with USRP, Part 4, and attach loss reports.)
1. Indicate the Reporting Period (Inception to Expiration Date) Indicate the Loss Valuation Date (Month/Year)
Reporting Period (Inception to Expiration Date) Month/Year
If there are no losses for this period, check this box to confirm that no losses were incurred during this reporting period and provide the
corresponding loss report.
2. Losses (See NOTE 2 of Instructions and Notes for Section G – Report of Payroll and Section H – Report of Losses.)
Claim Number
Accident
Date
MM/DD/YYYY
Injury
Type
(U S RP,
Part 4)
Classification
Code
Incurred Losses
Type of
Recovery
(USRP, Part 4)
Total Gross
Incurred Amt
(USRP, Part 4)
Type of
Settlement
(USRP, Part 4)
Fraudulent
Claim Code
(USRP, Part 4)
Open
(O)/
Closed
(F)
Cat.
No.Indemnity Medical
Fill in totals on the last page of each reporting period. Totals
Workers’ Compensation Insurance Rating Bureau of California
®
Request to Use California Self-Insured Data for Experience Rating Purposes
Form 701 (Rev. 01/2018)
Form RS701.18-0101
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 wcirb.com
Please number Section G — Report of Payroll and Section H — Report of Losses Pages
Sections F through H Must Be Completed If Not Submitting Self-Insured Data Electronically in
WCSTAT Format.
Name of Employer Employer Bureau Number (If Available)
Section G — Report of Payroll
1. Indicate the Reporting Period (Inception to Expiration Date)
Reporting Period (Inception to Expiration Date) See NOTE 1 of Instructions and Notes for Section G – Report of Payroll and Section H – Report of Losses.
2. Payroll (Not required for subsequent reports)
Classification Code Payroll
Classification Code Payroll
Workers’ Compensation Insurance Rating Bureau of California
®
Request to Use California Self-Insured Data for Experience Rating Purposes
Form 701 (Rev. 01/2018)
Form RS701.18-0101
WCIRB Customer Service 1221 Broadway, Suite 900 Voice 888.229.2472 customerservice@wcirb.com
Oakland, CA 94612 Fax 415.778.7272 wcirb.com
Please number Section G — Report of Payroll and Section H — Report of Losses Pages
Sections F through H Must Be Completed If Not Submitting Self-Insured Data Electronically in
WCSTAT Format.
Name of Employer Employer Bureau Number (If Available)
Section H — Report of Losses (Value claims in accordance with USRP, Part 4, and attach loss reports.)
1. Indicate the Reporting Period (Inception to Expiration Date) Indicate the Loss Valuation Date (Month/Year)
Reporting Period (Inception to Expiration Date) Month/Year
If there are no losses for this period, check this box to confirm that no losses were incurred during this reporting period and provide the
corresponding loss report.
2. Losses (See NOTE 2 of Instructions and Notes for Section G – Report of Payroll and Section H – Report of Losses.)
Claim Number
Accident
Date
MM/DD/YYYY
Injury
Type
(U S RP,
Part 4)
Classification
Code
Incurred Losses
Type of
Recovery
(USRP, Part 4)
Total Gross
Incurred Amt
(USRP, Part 4)
Type of
Settlement
(USRP, Part 4)
Fraudulent
Claim Code
(USRP, Part 4)
Open
(O)/
Closed
(F)
Cat.
No.Indemnity Medical
Fill in totals on the last page of each reporting period. Totals
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Self- Insured Data ( Form 701) (WCIRB California)

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Completed 15 July 2020

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