Form 807 - Coverage Research Service Request - Wcirb California

Download a blank fillable Form 807 - Coverage Research Service Request - Wcirb California in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 807 - Coverage Research Service Request - Wcirb California with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.


Workers’ Compensation Insurance Rating Bureau of California
Coverage Research Service Request
Form 807 (Rev. 05/2015)
Purpose of Form
• Under Coverage Information Requested, list both the
physical address and the P.O. Box address, if the
Completion of this form is required for coverage requests
employer uses a P.O. Box. The WCIRB can only provide
made in connection with a pending workers’ compensation
coverage information when the employer’s address
claim. It may also be used by employers or insurers to
matches the address on the policy record.
request their own coverage information.
Use of Form
The fee for coverage research is $10.00 per year,
The WCIRB can provide coverage information to an
per employer. Any portion of a year counts as a complete
insurance company, employer, injured worker, licensed
health care provider, Third Party Entity (TPE) acting on
behalf of a member insurer who has a TPE agreement with
Fee Examples
the WCIRB or an attorney involved in a pending workers’
The examples are based on one employer.
compensation claim.
Coverage Requested
Total No. Years
Before the coverage request will be processed, the
requesting party must certify that he/she is entitled
to receive the information, that the information will be
used solely in connection with the pending workers’
compensation claim and that the information will not be
otherwise published, distributed or released to third parties
other than in connection with the administration and/or
Payment must be received before your request can
litigation of the pending workers’ compensation claim.
be processed and is non-refundable. Calculating the correct
Employers or insurers may have access to their
fee for your request will expedite your order.
own information even if there is no pending workers’
If you need assistance in calculating the fee, call
compensation claim.
WCIRB Customer Service.
• WCIRB member insurers may elect to be billed.
Coverage Availability
• TPEs, authorized by WCIRB member insurers, may elect
The WCIRB is unable to supply coverage information prior to
to have the WCIRB bill the member insurer. The WCIRB
is unable to bill TPEs directly.
Information Requirements
• For all others, the WCIRB accepts payment by check
The WCIRB will not process your coverage research service
only. Include your payment when submitting the Coverage
request unless all sections of the form are completely filled
Research Service Request form.
The requesting party must provide the WCIRB with
Coverage research requests are mailed.
necessary information regarding the pending workers’
EMAIL Email delivery is available (see page 2).
compensation claim for which the information is sought,
including the name of the parties, date of injury, claim
Form Submission
number (if known) and WCAB number (if assigned).
This form must be mailed to the WCIRB.
Incomplete information will delay the completion of your
WCIRB Customer Service
Attn: Coverage Department
Form Completion
1221 Broadway, Suite 900
• This form can be completed electronically; however,
Oakland, CA 94612
the form requires a signature and must be printed and
signed by an authorized individual.
Call WCIRB Customer Service toll free
• If not completed electronically, print or type
888.CA.WCIRB (229.2472) 7:30 a.m.–5:00 p.m. PST
all information.
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.
1221 Broadway, Suite 900
Voice 888.229.2472
Oakland, CA 94612
Form CS807.15-0505


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Page of 4