Workers' Compensation Insurance

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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.

    When updating multiple licenses, as a security measure the online portal may stop allowing submissions from you. If this happens close your browser, re-enter the website, and then try to use the portal again.

    If you’re entering policy information for a Limited Liability Company (LLC) and need to update both general liability and workers’ compensation information, please use the general liability portal first.

    Once you have submitted this document the information will automatically update the CSLB database. Do not send any copies to CSLB. Please do a License Check to review the license status and insurance information. Check A License - CSLB (ca.gov)

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


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    Leasing and Insured Information

    *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


    Error populating Insurance Company Names. Please try again later.



    * 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
    • 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.

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