Policyholder Ombudsman – Request for Assistance

Before you file a request for assistance, contact your insurance company, agent or broker to resolve the issue(s) directly. If necessary, you may also contact the WCIRB. If you do not receive a satisfactory response, use this form to request assistance from the WCIRB Policyholder Ombudsman. Fill in the information below and click submit to send the request. Agents, brokers and insurers should contact the WCIRB Contact Center by calling 888.CA.WCIRB (888.229.2472).

Submitting Supporting Documentation

If you have supporting documentation, please use the web form below to attach electronic files. You may send hard copies of files to:

Workers' Compensation Insurance Rating Bureau of California
1901 Harrison Street, 17th Floor
Oakland, CA 94612
Attn: Policyholder Ombudsman

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Request for Assistance Form

First Name *

Middle Initial

Last Name *

Company Name *

Company Address 1 *

Company Address 2

Company City *

Company State *

Company Zip Code *

Telephone *

Email *

Fax

Referred By *

Name of insurance company or companies involved in the dispute

Agent/Broker Name

Agent/Broker Phone

Premium in Dispute

Have you reported this dispute to any government agency?

Yes

Have you previously contacted the WCIRB on this issue? *

Yes

Policy Number

Claim Number

Briefly state your problem

What would you consider a fair resolution?

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Policyholder Ombudsman – Request for Assistance

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Policyholder Ombudsman – Request for Assistance