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Applications and Forms


Massachusetts Workers Compensation Assigned Risk Pool Application For Workers Compensation Insurance

Employee Leasing Supplemental Application

Client of Labor Contractor Supplemental Application

Labor Contractor Supplemental Application

Construction Contractor Supplemental Application

Trucker/Delivery Supplemental Application

MA ERM Form - Confidential Request for Information

Massachusetts Assigned Risk Pool - Request for Certificate of Insurance

Massachusetts Construction Classification Premium Adjustment Program Application

Request for Massachusetts Qualified Loss Management Program Assigned Risk Credit


Workers Compensation Assigned Risk Pool Application For Workers Compensation Insurance (Effective January 1, 2017 - Edition 01)

The current application is effective January 1, 2017 - Edition 01.

Online Assigned Risk

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. You must be enrolled and have an agency account created to use OAR. To create an agency account, click on the Enrollment Information text link on the WCRIBMA home page.

Once the agency account and user name are created, you are ready to submit an application through OAR (Online Assigned Risk). Go to the home page and click on the red OAR or Online Assigned Risk text links which will bring you to the Login to OAR screen. Enter your user name and password and click on Log In which brings you to the OAR home page. To create an application click on the Create Application link located on the blue menu bar. Also, to check on the status of you current applications, click on the My Application link located on the blue menu bar.

For help in completing an OAR application, refer to the Pool Procedures - New Applications Submitted through OAR.

Hard Copy Applications

Effective 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. 

For help in completing a hard copy application, refer to the Pool 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 WCRIBMA 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.

MA WC Assigned Risk Application in PDF format for printing.

MA WC Assigned Risk Application in Word format which can be saved to your own file and completed in Word - is not yet available.


Employee Leasing Supplemental Application                                             (Effective 01/01/2017 - Edition 01)

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  section of this website.  

This application must be completed when the applicant leases employees to other businesses.  Complete a separate Pool application and a separate Employee Leasing Supplemental Application for each client to whom you lease employees.


Client of Labor Contractor Supplemental Application                            (Effective 01/01/2017 - Edition 01)

This application must be completed when the applicant regularly has employees provided to them by another business, whether from an employee leasing company, PEO, staffing agency, or temporary employment agency. In this situation the applicant is applying for assigned risk coverage for their direct employees.


Labor Contractor Supplemental Application                                                (Effective 01/01/2017 - Edition 01)

When a labor contractor provides employees to other businesses but does not consider them to be employee leasing arrangements as defined by 211 CMR 111.03, then the employer must complete and sign the Labor Contractor Supplemental Application and attach it to their application submission.


Construction Contractor Supplemental Application                                (Effective 01/01/2017 - Edition 01)

Applicants who operate as a general or subcontractor in commercial or residentail construction operations must complete the Construction Contractor Supplemental Application and attach it to their application submission.


Trucker/Delivery Supplemental Application                                                  (Effective 01/01/2017 - Edition 01)

Applicants who operate a trucking or delivery business must complete the Trucker/Delivery Supplemental Application and attach it to their application submission.


MA ERM Form - Confidential Request for Information
Updated form as of April 1, 2017

This form (2 pages) is used to detail the ownership of an entity or entities. It can be used to report the following situations and/or information to the WCRIBMA and the carrier:

  • report a name change,
  • determine combinability of separate entities for experience rating purposes,
  • report the sale, transfer or conveyance of an ownership interest,
  • report the sale, transfer or conveyance of an entity's physical assets to another entity which takes over its operations,
  • report a merger or consolidation,
  • report a voluntary or court-mandated establishment of a trustee or receiver, or
  • report the formation of a new entity that acts as, or in effect is, a successor to another entity.

MA ERM Form (PDF)  (Word doc)


Massachusetts Assigned Risk Pool - Request for Certificate of Insurance

This 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 of this website.

Request for Certificate of Insurance form in PDF format for printing.

Request for Certificate of Insurance form in Word format which can be saved to your own file and completed in Word.


Massachusetts Construction Classification Premium Adjustment Program Application

This application must be completed by an eligible employer and submitted to the WCRIBMA to apply for a construction classification premium credit. Page 2 of the application PDF includes instructions.  Applications may be submitted through our website using Online MCCPAP, located under the Tools and Services menu.  For more information, including the eligibility requirements, refer to the Massachusetts Construction Classification Premium Adjustment Program overview page on the website.

MA Construction Classification Premium Adjustment Application in PDF format for printing.

MA Construction Classification Premium Adjustment Application in Word format which can be saved to your own file and completed in Word.


Request for Massachusetts Qualified Loss Management Program Assigned Risk Credit

 This form is completed by both the qualified loss management firm and the subscribing employer and submitted to the WCRIBMA. Page 2 of the PDF outlines the General Terms of the Qualified Loss Management Program.

 

 

 

 

 

 

 

 

 

 

Resources

Residual Market Premium Algorithm / Calculator

Voluntary Market Premium Algorithm / Calculator

Class Code Lookup

Experience Rating, ARAP and
Merit Rating Calculator

Experience Rating History

Online MCCPAP - Construction Credit Application

Workers' Compensation Classification
Request Form

The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street, 5th Floor
Boston, MA 02110