Workers' Compensation Insurance

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Online Submission

This Workers' Compensation Insurance Online Submission process will walk the insurer through each field required by CSLB. This process was established to provide Insurance Companies with a way to submit Worker's Compensation policy information in real time.

Upon submission, this information will be directly input into CSLB's database (with the exception of a future effective date (within 30 days), these will be placed in a holding pattern and updated on the policy effective date).

You cannot use Online Submission if the insured is a leasing company or if this is a cancellation. Please continue to submit these with the required addendums by mail.

DO NOT use this form if you are the licensed contractor or applicant. Online Submission is ONLY to be completed by an insurer duly licensed to write worker's compensation insurance in this state (Business Professions Code 7125 (a)) or an authorized agent or employee of the insurer.


IMPORTANT INFORMATION:

Be sure to use the "Back" and "Next" buttons at the bottom of each page - DO NOT use your browser's back arrow because all of your entered information will be erased and you will have to start over.

Please type your information directly into the fields of this form. If you copy text from another application or document and paste it into this easy-fill form and the text contains invalid (non-ASCII) characters, they will be removed from the final document.

Make sure you give yourself enough time to complete the entire form in one sitting. You will not be able to save a partially filled form to complete at a later time.

* Required Field

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General Information and Instructions

This is an interactive process. You will not be permitted to continue if required items are incomplete.

NOTE: You cannot use this Online Submission Process if the insured is a leasing company or if this is a cancellation. Please continue to submit these with the required addendums by mail.

Prior to submission you will have a chance to review your answers. Once you have reviewed and agree to the contents, you will be allowed to proceed with submission.

Once you have submitted this document the information will automatically update the CSLB database. Do not send any copies to CSLB.

This information and final instructions will be provided upon completion of the process.


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Leasing and Insured Information

*Is the insured a leasing company or is this a cancellation?

* Required Field

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Producer Information

Please provide the Producer (i.e., the insurance agent/broker writing the policy and issuing the certificate) information below.

This form is ONLY to be completed by an insurer duly licensed to write workers' compensation insurance in this state.

Producer

Contact

* Required Field

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Coverages

The policy of insurance listed must be issued to the insured named in the document for the policy period indicated.

Workers Compensation and Employer' Liability

Insurer Affording Coverage

Select the Insurer Affording Coverage from the list below.

If the insurer is not found, please select "Insurer Not Found" from the list and submit the coverage by mail. If appropriate, CSLB will add the Insurer to the list



*California Policy Number (Refers only to a policy written to provide coverage in CA):


* Required Field

When you select "Next" you will be able to Review and Edit the information you have provided. This will be your chance to make any required corrections





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Required Notices

You cannot proceed to review the Easy-Fill form until you acknowledge the following Notices:

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES TO WHICH THIS CERTIFICATE PERTAINS. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.




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Review and Edit

Please Review the Following Information

This is a summary of what will print on your form. If there are any corrections that need to be made, please choose the Edit buttons to the right or Back Button on the bottom left to make the change now, as you will not have the opportunity to do so after you submit this page.


Reminder: Do Not use the browser's back and forward arrows.

Contact Information


Agree To Complete

You now have the option to add the certification information to the CSLB System or save/print the document to send at a later date.

Please select one of the following:

  • You will no longer be able to make changes
  • The information entered on this form will be added to the CSLB database
  • SET_IN_CODE
  • You will be directed to “Completion Instructions” where you have the opportunity to view a generated “For Your Records” copy of the document


  • You will no longer be able to make changes
  • The information entered on this form will NOT be added to the CSLB database
  • You will be directed to “Completion Instructions” where you will be able to review, print or save the PDF to your own device and mail at a later date

If you need to make any corrections to the provided information, please choose the Back or Edit buttons.
If you do not wish to continue this process, please select the Cancel button to return to CSLB’s Home Page.

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Completion Instructions

Workers’ Compensation Insurance has been Submitted

DO NOT SEND this data in a different format, either by mail, email or fax, as this may cause delays with information previously submitted.