Form 807 - Coverage Research Service Request - Wcirb California Page 2
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4Workers’ Compensation Insurance Rating Bureau of California
®
Coverage Research Service Request
Form 807 (Rev. 05/2015)
Original signature required. This form must be mailed.
Pending Workers’ Compensation Claim Information
Injured Worker
Date of Injury
Employer
WCAB Number (If Assigned)
Insurer (If Known)
Claim Number (If Known)
Requesting Party Information
Print Name of Individual Requesting Information
Title/Position
Company OR Injured Worker Represented
Telephone
Address (If Injured Worker, Include Your Own Address)
If an Attorney, Indicate Party Represented
City
State
Zip
Email Address (Required for Email Delivery)
Coverage Information Requested [For additional employers, attach separate sheet(s).]
The WCIRB is unable to supply coverage information prior to 1958.
List the physical address and if the employer has a P.O. Box, the P.O. Box must also be included.
(1)
(2)
Employer
Employer
DBA (If Known)
DBA (If Known)
Coverage Year(s) Requested
Coverage Year(s) Requested
Physical Address
Physical Address
Physical Address City
Physical Address City
Physical Address State
Zip
Physical Address State
Zip
P.O Box Address
P.O. Box Address
P.O Box City
P.O. Box City
P.O Box State
Zip
P.O. Box State
Zip
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WCIRB Customer Service
1221 Broadway, Suite 900
Voice
888.229.2472
Oakland, CA 94612
Fax
415.778.7272
Form CS807.15-0505
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