2013 EMPLOYER APPLICATION/ASSESSMENT FORM

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Workers Compensation Research Institute

2013 EMPLOYER APPLICATION/ASSESSMENT FORM

Our organization would like to become a member of the Workers Compensation Research Institute. We have read the material describing WCRI, including the Bylaws, and agree to the terms of membership.

The membership application form may be completed in two ways.

An application form may be completed and submitted on line.
An application form may be completed, printed and mailed to the Institute.

Please complete all fields on the application form, including the Primary Contact on the Member Distribution list, before submitting the application.

COMPANY:
ADDRESS:
ADDRESS 2:
CITY:
STATE:
ZIP:
PHONE:
FAX:
PRIMARY BUSINESS:
FULL-TIME U.S. EMPLOYEES:
ASSESSMENT:

DATES OF MEMBERSHIP: (check one) from January 1, 2013 to December 31, 2013 from July 1, 2013 to June 30, 2014

SUBMITTED BY:
DATE:

The 2013 employer assessment formula is:

73 cents for each of the first 10,000 domestic employees;
37 cents for each of the next 40,000 employees;
15 cents for each of the remaining employees

The employer assessment formula recognizes three groups according to the general level of hazard in the industry:

Group A: Principal business in construction, most manufacturing, mining, agriculture

pays 100% of the assessment formula

Group B: Principal business in light manufacturing, transportation and public utilities, certain service industries

pays 80% of the assessment formula

Group C: Principal business in retail, wholesale trade, financial services and most other services

pays 60% of the assessment formula

All groups are subject to a $20,000 maximum assessment and a $6,300 minimum assessment.

Member Distribution List

In order that we may disseminate information about the Institute and our research to the appropriate people within your organization, please designate those who should receive our communications.

The Primary Contact is the person who represents your organization in all matters requiring votes. The Alternate is the designee to act in the absence of the Primary Contact. All individuals listed receive WCRI FLASHREPORTS and other electronic communications keeping those on your list informed in advance of the latest WCRI research.

Primary Contact:
Name:
Email address:
Title:
Company address:
City:
State:
Zip:
Phone Number:

Alternate Contact:
Name:
Email address:
Title:
Company address:
City:
State:
Zip:
Phone Number:

Please check to see that all information is correct and then click Submit Application. We will invoice you for the assessment fee.

If paying by check, please print this form and mail with the payment to the address below.

Workers Compensation Research Institute
955 Massachusetts Avenue
Cambridge, MA 02139

For further information, please contact WCRI at 617-661-9274 or email us at wcri@wcrinet.org.

955 Massachusetts Avenue Cambridge, Massachusetts 02139 617-661-WCRI (9274)