Online Workers’ Comp Submission

Online WC Submission

  • WIAA Online Worker's Comp Submission

    You may submit this form instead of an Acord 130 for a WC quote. 3-5 Years Loss Runs must be included for a firm quote and you may upload them at the end of the application. Call 800-553-4221 if you experience any issues with this form.
  • or WIAA Subproducer Code
  • Applicant and Risk Information

  • Include First, Last and Business Name
  • WIAA has a market for "Lapses in Coverage" and "Employees already working"
  • Consult Work Comp Eligible List for Code
  • Or indicate if not applicable.
  • Example: Plastics MFG
  • Payroll Per Class Code

  • Individuals Included/Excluded

  • Name, Date of Birth, Title/Relationship to Insured, Ownership %, Include or Exlcude
  • Name, Date of Birth, Title/Relationship to Insured, Ownership %, Include or Exlcude
  • Name, Date of Birth, Title/Relationship to Insured, Ownership %, Include or Exlcude
  • Name, Date of Birth, Title/Relationship to Insured, Ownership %, Include or Exlcude
  • Prior Carrier Information

    List prior carriers and premium total for the prior 4 years. Please indicate N/A if not applicable.
  • Loss Runs/Other Attachments Upload Area

    Please upload 3-5 Years CV Loss Runs