Skip to main content
Labor and Economic Opportunity

WC-400 (8/19) - Insurer's Notice of Issuance of Policy (fill-in form)

Form WC-400 utilizes Optical Character Recognition (OCR) to scan data.  In order for the OCR function to work properly, a submitted form must be identical to the WC-400 provided on the Workers’ Disability Compensation Agency website, including but not limited to language, block space and positioning, font and dimension.  When data is input into the form, Arial 10 point font must be used, with each field limited to one line of data.

Therefore, this form can’t be handwritten and must be either mailed or submitted through the File Transfer Service (FTS). The FTS Application provides further information.

Forms not complying with these requirements will be rejected and returned unprocessed.

Click here for Form WC-400