Form 807 - Coverage Research Service Request - Wcirb California Page 4

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Workers’ Compensation Insurance Rating Bureau of California
®
Coverage Research Service Request
Form 807 (Rev. 05/2015)
Payment Method — Members and TPEs
WCIRB Member Billing.
I am authorized by the insurer named in the Requesting Party Section of this form to request insurance policy information. I
understand that my company will be billed for the information ordered by this form.
Authorized by
Authorized Signature Required
Title
Date
Member Authorized TPE. (Member will be billed. Include member billing information below.)
Authorized by
Signature
Title
Date
Member Company
Address
City
State
Zip
Payment Method — Others
The WCIRB accepts payment by check only. Make your check payable to “WCIRB” and mail to the address on this form.
Check enclosed (non-refundable).
Email Delivery
Check this box for email delivery as an alternative to receiving via U.S. Mail.
3 of 3
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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