Applications and Forms
Compensation Assigned Risk Pool Application For Workers Compensation
Massachusetts Workers' Compensation
Insurance Employee Leasing Supplemental Application
Massachusetts Temporary Employment
MA ERM Form - Confidential Request for Information
Massachusetts Assigned Risk Pool
- Request for Certificate of Insurance
Classification Premium Adjustment Program Application
Request for Massachusetts
Qualified Loss Management Program Assigned Risk Credit
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Workers' Compensation Assigned Risk Pool Application For Workers'
Compensation Insurance (Effective January
28, 2008- Edition 02)
current application is effective January 28, 2008 - Edition
On January 1, 2013 WCRIBMA made it mandatory for all producers
to use Online Assigned Risk (OAR) when submitting a MA Workers’
Compensation Assigned Risk Pool (MWCARP) application. (Refer
Bulletin 06-12.) To submit an application through OAR
(Online Assigned Risk) go to the Online Assigned Risk
home page to log in. You
must be a member of the WCRIBMA’s website to use OAR.
The Group Membership application (Producers and Employers Online
Assigned Risk application and instructions) is available on
the Online Assigned Risk home page.
help in completing an OAR application, refer to the Pool
Procedures - Submitted through OAR.
February 15, 2013, there is a $10 processing fee per application
for any hard copy application submitted by a producer to the
MA Workers’ Compensation Assigned Risk Pool. (Refer to
For help in completing a hard copy application, refer to the
Procedures - New Applications Submitted by Hard Copy.
The hard copy application (4 pages) must be completed by the
employer, with or without the assistance of a producer of record,
and submitted to the WCRIB with the appropriate deposit premium
and attachments to request assigned risk coverage through the
Massachusetts Workers' Compensation Assigned Risk Pool.
An original form is not required.
Workers' Compensation Insurance Employee Leasing Supplemental
Application (Revised November 1, 2002)
If an employee leasing
arrangement exists, according to Massachusetts Regulation 211
CMR 111.00, the Employee Leasing Supplemental Application must
be completed. For more information on employee leasing arrangements,
refer to Employee
Leasing Arrangements in the Program Overviews section of
A of the application must be completed when the applicant
leases employees TO another business. This Supplemental
Application is required in order that the applicant, the employee
leasing company, can provide information on the client and
the labor that they provide to that client. A separate application
must be made for each client to whom the applicant leases
B of the application must be completed when the applicant
leases employees FROM another business. In this situation
the applicant is applying for assigned risk coverage for their
non-leased employees. This Supplemental Application is required
in order that the applicant, the client of an employee leasing
company, can provide information on the employee leasing company
and the labor that is provided to them by the employee leasing
Temporary Employment Affidavit
a provider of temporary employees makes application for coverage
in the Massachusetts Assigned Risk Pool, the employer must complete
and sign the Massachusetts Temporary Employment Affidavit and
attach it to their application submission.
ERM Form - Confidential Request for Information
form (2 pages) is used to detail the ownership of an entity
or entities. It can be used in many different situations to
convey information necessary to the WCRIB and the carrier. Use
the ERM-14 Form to:
- report a name change,
- determine combinability of separate entities for experience
- report the sale, transfer or conveyance of an ownership
- report the sale, transfer or conveyance of an entities physical
assets to another entity which takes over its operations,
- report a voluntary or court-mandated establishment of a
trustee or receiver,
- report the formation of a new entity, or
- report a merger or consolidation.
ERM Form in PDF format for printing.
Form in Word format which can be saved to your own file
and completed in Word. The following link provides brief instructions
for this format.
Assigned Risk Pool - Request for Certificate of Insurance
form (2 pages) is used to request a Certificate of Insurance
from an Assigned Risk Pool Carrier. For more information on
the procedure and where to mail or fax this form, refer to the
Certificates of Insurance
page in the Producer Community section of this website.
Construction Classification Premium Adjustment Program Application
application must be completed by an eligible employer and submitted
to the WCRIB to apply for a construction classification premium
credit. Applications may be submitted through our website using
located under the Products and Services menu. Page 2 of the
PDF includes instructions. For more information, including the
eligibility requirements, refer to the
Massachusetts Construction Classification Premium Adjustment
Program in the Program Overviews section of this website.
for Massachusetts Qualified Loss Management Program Assigned Risk
form is completed by both the qualified loss management firm
and the subscribing employer and submitted to the WCRIB. Page
2 of the PDF outlines the General Terms of the Qualified Loss