WKC-18151-E, New Insurance or Insurance Change
Department of Workforce Development
Worker's Compensation Division
New Insurance or Insurance Change
|Legal Name of Insurance Company |
| |
|Address |
| |
|Group Name |
| |
|Federal Employer Identification Number (FEIN) |North American Industry Classification (NAIC) Code |
| | |
|National Council on Compensation Insurance (NCCI) Number |WI Unemployment Insurance (UI) Number (if applicable) |
| | |
|Name of Contact Person |Title |
| | |
|Email Address |
| |
|Phone Number |Fax Number |
| | |
|Per §102.35, Wis. Stats., provide an address to which the department shall submit surcharges |
| |
|Name of individual completing this form |Date form completed |
| | |
|Signature of individual completing this form |
|Per §102.31(3), Wis. Stats., provide a single, default mailing address for department correspondence. If the carrier administers its own claims, then oftentimes |
|the 102.31(3) address is the same as the carrier's claim handling office (CHO) address. If that is the case, then enter the address in this block. The 102.31(3) |
|address can also be the same as a Third Party Administrator's (TPA) CHO address. If that is the case, then in the section below, check the 102.31(3) box next to |
|the appropriate TPA. |
| |
|If applicable, please provide the following information for each Third Party Administrator handling your claims |
|Legal Name of Third Party Administrator §102.31(3), Wis. Stats., address |
| |
|Address |
| |
|TPA Start Date (if relevant) |TPA End Date (if relevant) |
| | |
|Federal Employer Identification Number (FEIN) |Unemployment Insurance (UI) Number |
| | |
|Name of Contact Person |Title |
| | |
|Email Address |
| |
|Phone Number |Fax Number |
| | |
|Name of Individual completing this form |Date form completed |
| | |
|Signature of Individual completing this form |
WKC-18151-E (R. 02/2019)
|Third Party Administrator Information |
|Legal Name of Third Party Administrator §102.31(3), Wis. Stats., address |
| |
|Address |
| |
|TPA Start Date (if relevant) |TPA End Date (if relevant) |
| | |
|Federal Employer Identification Number (FEIN) |Unemployment Insurance (UI) Number |
| | |
|Name of Contact Person |Title |
| | |
|Email Address |
| |
|Phone Number |Fax Number |
| | |
|Name of Individual completing this form |Date form completed |
| | |
|Signature of Individual completing this form |
|Third Party Administrator Information |
|Legal Name of Third Party Administrator §102.31(3), Wis. Stats., address |
| |
|Address |
| |
|TPA Start Date (if relevant) |TPA End Date (if relevant) |
| | |
|Federal Employer Identification Number (FEIN) |Unemployment Insurance (UI) Number |
| | |
|Name of Contact Person |Title |
| | |
|Email Address |
| |
|Phone Number |Fax Number |
| | |
|Name of Individual completing this form |Date form completed |
| | |
|Signature of Individual completing this form |
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