Wcirb Form 807 PDF Details

In the realm of workers' compensation in California, the need for accurate and accessible coverage information cannot be overstated. This necessity is well addressed by the Workers' Compensation Insurance Rating Bureau of California (WCIRB) through its Coverage Research Service Request Form 807. This form serves as a vital tool for insurance companies, employers, injured workers, licensed health care providers, attorneys, and Third Party Entities (TPE) who seek detailed information concerning workers' compensation insurance coverage relative to specific claims. The process is stringent; applicants must affirm their entitlement to the requested information, underscoring its intended use solely for pending workers’ compensation claims. It is set against a backdrop where full, detailed completion of the form is non-negotiable for processing requests, emphasizing a structure designed to streamline and ensure the validity of requests. Additionally, the form’s guidelines on payment, including the fee structure per coverage year per employer and specifics on billing and payment submission, underscore its comprehensive approach to servicing coverage research needs. With options for receiving information via email or traditional mail, alongside accessible customer service, the WCIRB outlines a well-structured pathway for stakeholders within California’s workers' compensation system to access pivotal coverage information.

QuestionAnswer
Form NameWcirb Form 807
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other names1958, wcirb form 807, OPQ, 2001

Form Preview Example

Workers’ Compensation Insurance Rating Bureau of California

Coverage Research Service Request

Form 807

Instructions

Who Can Use the Coverage Research Service

The WCIRB can provide coverage information to an 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 the WCIRB, or an attorney involved in a pending workers' compensation claim. 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 litigation of the pending workers' compensation claim. Employers or insurers may have access to their own information even if there is no pending workers’ compensation claim.

Requirements

Completion of the Coverage Research Service Request Form is required for coverage requests made in connection with a pending workers' compensation claim.

The WCIRB will not process your coverage research service request unless all five sections of the form are completely filled out. The requesting party must provide the WCIRB with necessary information regarding the pending workers' compensation claim for which the information is sought, including the name of the parties, date of injury, claim number (if known), and WCAB number (if assigned). Incomplete information will delay the completion of your request.

Form Completion

Please print or type

This form can be completed electronically but requires a signature and must be mailed to the WCIRB

Please complete all necessary information on page 1 and page 2

If you need additional information, please call WCIRB Customer Service

To Request Coverage Research

Mail WCIRB Customer Service

525 Market Street, Suite 800

San Francisco, CA 94105-2767

Fees

The fee for coverage research is $8.00 per coverage year per employer. For example, the fee for a research request for one employer for one year is $8.00. The fee for a research request for one employer for policy years 1998-1999 is $16.00. The fee for a research request for ABC Corp., XYZ Corp. and OPQ Corp. for the 2001 policy year is $24.00.

Payment

Payment must be received before your request can be processed.

WCIRB member insurers may elect to be billed.

TPEs, authorized by WCIRB member insurers, may elect to have the WCIRB bill the member insurer. The WCIRB is unable to bill TPEs directly.

For all others, the WCIRB accepts payment by check only. Please include your payment when submitting the Coverage Research Service Request Form.

Shipping

Mail Coverage research requests will be mailed.

Email If you want to receive the information by email, please be sure to check the designated box on the order form.

Questions

Call WCIRB Customer Service toll free

888.CA WCIRB (229.2472) 7:30 a.m.–5:00 p.m. PST.

WCIRBCALIFORNIA®

WCIRB CUSTOMER SERVICE

525 Market Street, Suite 800

San Francisco, CA 94105-2767

Voice 888.229.2472

customerservice@wcirbonline.org

www.wcirbonline.org

Form 807-CS1105

Coverage Research Service Request

Form 807

ELECTRONIC FORM

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)

 

 

Certification

 

The requesting individual hereby certifies that he/she is:

 

the injured worker in the pending workers' compensation claim; OR

an employee, partner, manager, officer, director, or owner of, and has the authority to bind:

a licensed workers' compensation insurance insurer in the pending workers' compensation claim; an employer, as defined by Labor Code Section 3300, in the pending workers' compensation claim; a licensed health care provider in the pending workers' compensation claim;

a Third Party Entity (TPE) that is authorized by a member insurer to obtain coverage information;

; OR

TPE Name

Member Insurer Name

an attorney representing any of the above individuals or entities in the pending workers' compensation claim.

Coverage Information Requested

For additional employers, attach a separate sheet. The WCIRB is unable to supply coverage information prior to 1958.

(1)

(2)

 

 

Employer

Employer

 

 

Address

Address

 

 

City/State/Zip Code

City/State/Zip Code

 

 

Coverage Year(s) Requested

Coverage Year(s) Requested

1 of 2

WCIRB Customer Service

525

Market Street, Suite 800

Voice

888.229.2472

customerservice@wcirbonline.org

 

San

Francisco, CA 94105-2767

Fax

415.778.7272

www.wcirbonline.org

 

 

 

 

 

 

Form 807-CS1105

WCIRB USE ONLY: CONTROL #

Coverage Research Service Request

Form 807

ELECTRONIC FORM

Signature required. This form must be mailed.

Restricted Use of Information

I agree that the coverage information provided shall be used solely in connection with the administration and/or litigation of the above-referenced pending workers' compensation claim, and for no other purpose. In addition, I agree that the information provided by the WCIRB is confidential and proprietary and shall not be published, distributed, released or communicated to third parties, other than in relation to the administration and/or litigation of the above- referenced pending workers' compensation claim. I affirm that all information provided on this form is true and correct.

Signature

Date

Delivery

Check this box for email delivery.

Payment (See instructions.)

The WCIRB accepts payment by check only.

Please make your check payable to "WCIRB" and mail to the address on this form.

Fee enclosed (nonrefundable) $ _______________________

Bill My Company

(WCIRB member insurers and authorized TPEs only. See instructions.)

2 of 2

WCIRB Customer Service

525

Market Street, Suite 800

Voice

888.229.2472

customerservice@wcirbonline.org

 

San

Francisco, CA 94105-2767

Fax

415.778.7272

www.wcirbonline.org

 

 

 

 

 

 

Form 807-CS1105

WCIRB USE ONLY: CONTROL #

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insurer completion process clarified (step 1)

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Completing section 2 of insurer

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