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Policyholder Experience Rating Worksheet Request Form

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Policyholder Experience Rating Worksheet Request Form

* required field

You must be the policyholder to obtain a free copy of your most current Experience Rating Worksheet using this form.

If you received a postcard from the WCIRB containing your company's Bureau Number (located near your company address), please enter it below. The Bureau Number is not a required field.

You must enter your current policy number. The policy number may be found on your workers' compensation policy documents. If you cannot locate your policy number, you should contact your insurance professional or insurer. The WCIRB cannot provide your policy number to you and cannot process your request without it.

The WCIRB will send you the most current Experience Rating Worksheet available. If your anniversary rating date is more than 30 days in the future, the rate sheet you receive may be for your current policy instead of your future policy period.

Please allow up to 30 days for processing. Incomplete or inaccurate information may delay processing your request.

If you request your Experience Rating Worksheet to be sent via email, it will be sent as an Adobe® Acrobat® PDF file. If you do not have the free Adobe Acrobat Reader, you may download it from Adobe's website.

By clicking Submit below, you declare that you are the policyholder or an employee of the policyholder that is authorized to obtain this information on behalf of your company. Email distribution is not a secure method of delivery and if you request distribution by email, you agree to accept that risk and hold the WCIRB harmless from any liability associated with that form of distribution.