Overage requests made in connection with a pending workers compensation claim. Use of Form The WCIRB can provide coverage information to an insurance company, employer, injured worker, licensed health care provider, Third Party Entity (TPE) acting on behalf of a member insurer who has a TPE agreement with the WCIRB or an attorney involved in a pending workers compensation claim. Authorization Before the coverage request will be processed, the requesting party must certify that he/she is en.
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How to fill out the Form 807 online
Filling out the Form 807 is essential for obtaining coverage information related to a pending workers' compensation claim. This guide will provide you with clear, step-by-step instructions to successfully complete the form online.
Follow the steps to complete Form 807 with ease.
- Click the ‘Get Form’ button to access the form and open it in your editor.
- Provide the necessary information in the 'Pending Workers’ Compensation Claim Information' section, including the injured worker's name, date of injury, employer details, claim number (if known), and WCAB number (if assigned). Ensure all relevant fields are filled to avoid processing delays.
- In the 'Requesting Party Information' section, enter the name of the individual requesting information, their title or position, company name or the injured worker represented, phone number, email address, and complete address, ensuring it is the correct information for correspondence.
- Complete the 'Coverage Information Requested' section. List the physical address of the employer and include the P.O. Box address if applicable. Remember that the WCIRB needs the addresses to match policy records.
- In the 'Certification' section, indicate your status as the injured worker, an employee, a licensed insurer, a health care provider, a Third Party Entity, or an attorney representing one of these parties. Sign and date the certification to confirm your assertion.
- List the amount to be paid according to the fee schedule provided. Payment is required for processing the request.
- Choose your payment method. If you are using a check, make it payable to 'WCIRB' and ensure it is enclosed when you submit the form or arrange for member billing if applicable.
- Finally, review all provided information for accuracy before submitting. Once you have completed the form, print it, sign it, and mail it to the WCIRB address provided in the instructions.
Start filling out Form 807 online today to request your workers' compensation coverage information.
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