Fillable Form 22531 Form 1101,  (WCIRB California)

Fill Online, Printable, Fillable, Blank Form 22531 Form 1101,  (WCIRB California) Form

Use Fill to complete blank online WCIRB CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 22531 Form 1101,  (WCIRB California)

On average this form takes 11 minutes to complete

The Form 22531 Form 1101,  (WCIRB California) form is 3 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 44 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your WCIRB California forms online.

BROWSE WCIRB CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Workers’ Compensation Insurance Rating Bureau of California
®
Form FIA1101.18-0919
1221 Broadway, Suite 900 accountingdept@wcirb.com
Oakland, CA 94612 wcirb.com
New Member Application
Form 1101 (09/2018)
Purpose of Form
This form is used to apply for membership in the WCIRB.
Every insurer authorized to transact California workers’
compensation insurance and employers’ liability insurance
incidental thereto and written in connection therewith is
eligible for membership in the WCIRB.
Use of Form
This form is used by insurers who are applying to the California
Department of Insurance for a Certificate of Authority to
transact workers’ compensation insurance in California.
Section A — Insurer Information
Provide the name of Insurer and the following:
• Insurer Address
The Primary Address of the Insurer corporate office.
• Insurer Contact
The Contact is the person with whom the WCIRB will
communicate regarding the application process.
• NAIC #
Each Insurer is required to provide their NAIC #.
• NAIC Group Affiliation
Provide the NAIC Group Number and Name if applicable.
Section B — Billing Contact Information
Provide the name, address and contact information for which
invoices should be directed.
Section C — Officer Signatory Information
Provide the name, title and contact information for the Officer
of the Insurer responsible for signing the WCIRB Constitution
and By-Laws.
Section D — Membership Level
Select from the two types of Membership levels available.
Section E — Contact Information of Person
Submitting Application
Provide the name and contact information of the person
submitting the application to WCIRB.
Form Submission
This form may be completed electronically or manually. It
may be scanned and emailed or mailed:
EMAIL accountingdept@wcirb.com
MAIL WCIRB, Accounting
1221 Broadway, Suite 900
Oakland, CA 94612
Questions/Additional Information
Call the WCIRB Accounting Specialist, Member Services at
415.778.7089 between 8:00 AM to 4:30 PM.
Instructions
Workers’ Compensation Insurance Rating Bureau of California
®
New Member Application
Form 1101 (09/2018)
Form FIA1101.18-0919
WCIRB 1221 Broadway, Suite 900 accountingdept@wcirb.com
Finance Oakland, CA 94612 wcirb.com
2
Section A — Insurer Information
This section identifies the Insurer and Insurer Group information.
Name of Insurer NAIC Number
Name of Insurer Group (if applicable) NAIC Group Number (if applicable/known)
Insurer Address City State Zip
Primary Contact
The Primary Contact should be knowledgeable about how the Insurer company or group of companies reports data to the
WCIRB and should have the authority to act on behalf of the Insurer company or group.
Name Title
Address City State Zip
Telephone Email
Section B — Billing Contact Information
Provide the name, address and contact information for which invoices should be directed.
Name Title
Company Name
Address City State Zip
Telephone Email
Section C — Officer Signatory Information
Upon issuance of the Certificate of Authority by the California Department of Insurance, an officer of the Insurer will be required
to sign the WCIRB Constitution and By-Laws. The documents will be sent via DocuSign.
Name of Officer Title
Telephone Email
Workers’ Compensation Insurance Rating Bureau of California
®
New Member Application
Form 1101 (09/2018)
Form FIA1101.18-0919
WCIRB 1221 Broadway, Suite 900 accountingdept@wcirb.com
Finance Oakland, CA 94612 wcirb.com
3
Name of Insurer NAIC Number
Name of Insurer Group (if applicable) NAIC Group Number (if applicable/known)
Section D — Membership Level
There are two types of membership available.
A regular member is an eligible insurer with direct written premium at the advisory pure premium rate level of at least $500,000
in the latest available calendar year or has selected to become a regular member by paying the regular membership fee. Only
regular members are entitled to vote, hold office or serve as members of committees.
An associate member is an eligible insurer with direct written premium at the advisory pure premium rate level of less than
$500,000 in the latest available calendar year.
Please select membership level:
Regular Membership - $1,500 annual fee Associate Membership - $500 annual fee
A membership fee invoice will be generated upon execution of the WCIRB Constitution and By-Laws. WCIRB invoices are due
upon receipt.
Section E — Contact Information of Person Submitting Application
Provide the name and contact information of the person submitting the application to WCIRB.
Name Title
Company Name
Address City State Zip
Telephone Email
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 22531 Form 1101, (WCIRB California)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document