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). If you do not have Microsoft Word we are providing a PDF (WKC-18151) which you can print and complete by hand.
Content Contact: Lynn Weinberger
WKC-18151-E (Electronic Version - Word/89 KB)
WKC-18151 (Print Version - pdf/11 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.