Department of Workforce Development Worker's Compensation Division New Insurance or Insurance Change Legal Name of Insurance Company Address Group Name Federal Employer Identification Number (FEIN) North American Industry Classification (NAIC) Code National Council on Compensation Insurance (NCCI) Number WI Unemployment Insurance (UI) Number (if applicable) Name of Contact Person Title Email Address Phone Number Fax Number Per 247102.35, Wis. Stats., provide an address to which the department shall submit surcharges Name of individual completing this form Date form completed Signature of individual completing this form Per 247102.31(3), Wis. Stats., provide a single, default mailing address for department correspondence. If the carrier administers its own claims, then oftentimes the 102.31(3) address is the same as the carrier's claim handling office (CHO) address. If that is the case, then enter the address in this block. The 102.31(3) address can also be the same as a Third Party Administrator's (TPA) CHO address. If that is the case, then in the section below, check the 102.31(3) box next to the appropriate TPA. If applicable, please provide the following information for each Third Party Administrator handling your claims Legal Name of Third Party Administrator 247102.31(3), Wis. Stats., address Address TPA Start Date (if relevant) TPA End Date (if relevant) Federal Employer Identification Number (FEIN) Unemployment Insurance (UI) Number Name of Contact Person Title Email Address Phone Number Fax Number Name of Individual completing this form Date form completed Signature of Individual completing this form WKC-18151 (R. 02/2019) American LegalNet, Inc. www.FormsWorkFlow.com Third Party Administrator Information Legal Name of Third Party Administrator 247102.31(3), Wis. Stats., address Address TPA Start Date (if relevant) TPA End Date (if relevant) Federal Employer Identification Number (FEIN) Unemployment Insurance (UI) Number Name of Contact Person Title Email Address Phone Number Fax Number Name of Individual completing this form Date form completed Signature of Individual completing this form Third Party Administrator Information Legal Name of Third Party Administrator 247102.31(3), Wis. Stats., address Address TPA Start Date (if relevant) TPA End Date (if relevant) Federal Employer Identification Number (FEIN) Unemployment Insurance (UI) Number Name of Contact Person Title Email Address Phone Number Fax Number Name of Individual completing this form Date form completed Signature of Individual completing this form American LegalNet, Inc. www.FormsWorkFlow.com