Form 807 - Coverage Research Service Request - Wcirb California

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Workers’ Compensation Insurance Rating Bureau of California

Coverage Research Service Request

Form 807 (Rev. 05/2015)

Instructions

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.

Fees

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

year.

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

Fee

Authorization

2009–2010

$20

Before the coverage request will be processed, the

1/1/09–1/1/10

$10

requesting party must certify that he/she is entitled

1/1/09–1/31/10

$20

to receive the information, that the information will be

2009–3/1/12

$40

used solely in connection with the pending workers’

2008–2012

$50

compensation claim and that the information will not be

otherwise published, distributed or released to third parties

Payment

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

1958.

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.

out.

Delivery

The requesting party must provide the WCIRB with

MAIL

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

MAIL

WCIRB Customer Service

request.

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

Questions

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.

WCIRB

1221 Broadway, Suite 900

Voice 888.229.2472

California

Oakland, CA 94612

Fax

415.778.7272

Objective.Trusted.Integral.

Form CS807.15-0505