Document Number: WKC-18151-E
Description: This form is used for collecting pertinent information from new Workers' Compensation insurance carriers as well as updating changes in information. The form also provides a section to submit or update information pertinent to Third Party Administrators.
Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word). An electronic PDF (WKC-18151-E) is also provided for your convenience.
Content Contact: Lynn Weinberger
WKC-18151-E (Electronic Version - Word/89 KB)
WKC-18151-E (Electronic Version - pdf/11 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.