The Oregon 4821 form serves as the Proof of Coverage EDI Insurer Profile for the Workers’ Compensation Division. Insurers must fill out this form prior to submitting or allowing a vendor to send proof-of-coverage data electronically. Each subsidiary insurer within an insurance group that is licensed to write workers’ compensation insurance in Oregon requires its own separate form.
The Oregon 4821 form serves as a critical document for insurers operating within the state, particularly in the realm of workers' compensation coverage. Before any insurer can submit or allow a vendor to submit proof-of-coverage data electronically through the Electronic Data Interchange (EDI), this form must be completed. It requires detailed information about the insurer, including the name and Federal Employer Identification Number (FEIN), which are essential for accurate record-keeping and compliance. Each subsidiary insurer within an insurance group must submit a separate form, ensuring that all entities are properly documented. Additionally, the form includes sections for authorizing a vendor to handle EDI submissions on behalf of the insurer, along with contact information for both business and technical representatives. This ensures that there is a clear line of communication for any issues or inquiries related to proof-of-coverage data. Lastly, the form must be signed and dated, marking the completion of the profile and indicating any previous profiles it may replace. Proper submission of the Oregon 4821 form is vital for maintaining compliance and ensuring that workers are covered under the appropriate insurance policies.
Form 4821: Oregon Proof of Coverage
EDI Insurer Profile
Workers’ Compensation Division
Insurers must complete this form before submitting or authorizing a vendor to send proof-of-coverage data to the department through electronic data interchange (EDI). If an insurer is direct reporting proof-of-coverage information, list the insurer name and FEIN under the vendor section.
A separate form is required for each subsidiary insurer within an insurance group that is licensed to write workers’ compensation insurance in Oregon.
Insurer name
Insurer FEIN
The following vendor is hereby authorized to submit EDI proof-of-coverage data on behalfof the insurer listed above:
Vendor name
Vendor FEIN
Contact information for EDI proof-of-coverage business contact:
Business contact name
Title
E-mail address
Address
City
State
ZIP
Phone
Contact information for EDI proof-of-coverage technical contact:
Technical contact name
Contact information for person who prepared profile information, if different from above:
Name
Authorizedsignature
Date profile prepared:
Replaces profile dated:
(for vendor change)
Complete and return to the WCD EDI Coordinator
By fax: 503-947-7514
By e-mail: edinews.wcd@state.or.us
440-4821(08/08/DCBS/WCD/WEB)
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