WCIRB Contact Center Inquiry Form

* required field

Please view our Frequently Asked Questions page for answers to many questions. Please fill out the form below to submit your inquiry to Customer Service and include as much detail as possible, e.g. policy number, bureau number, etc. the WCIRB Contact Center will respond to your inquiry within 5 business days.

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Choose which applies to you: *

First Name *

Last Name *

Company Name (If you are an injured worker, please put "injured worker"in the field) *

Company Address 1 (If you are an injured worker, please provide your mailing address) *

Company Address 2

City *

State *

Zip Code *

Email Address *

Telephone *

Fax

Bureau Number

FEIN

Policyholder Information

Policyholder's First Name

Policyholder's Last Name

Company Name

Company Address 1

Company Address 2

City

State

Zip Code

Policy Number

Question Topics *

If you have a question about your experience modification, please provide the effective date of the experience modification.

Please provide your inquiry in the space below.

Topics:

WCIRB Contact Center Inquiry Form

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WCIRB Contact Center Inquiry Form

Policyholder Information