State of New York - Workers’ Compensation Board REQUEST FOR ACCESS TO SUBMIT CLAIM FORMS ON THE WEB Electronic Business Application This Request Pertains To: Organization Type Eligible to Apply (see table below) Web Submission of Claim Forms Does organization already have access to Web Submission of Yes No Claim Forms? a, b, c, d, e, f, possibly g For information about this application, including minimum requirements, visit the Board’s web site at www.wcb.state.ny.us. Click e-bizWCB and then click on the electronic business application you are interested in. PLEASE NOTE: USER IDs AND PASSWORDS ARE ASSIGNED TO INDIVIDUALS REPRESENTING COMPANIES, NOT TO THE ORGANIZATION. AN ORGANIZATION WILL NOT GET A SINGLE USER ID FOR ITS EMPLOYEES. INSTEAD, A USER ID WILL BE ASSIGNED TO EACH EMPLOYEE FOR THE e-BIZ APPLICATION, AS REQUESTED ON THIS FORM. ORGANIZATION NAME AND ADDRESS WEB SUBMISSION OF CLAIM FORMS ADMINISTRATOR’S NAME AND ADDRESS E-MAIL ADDRESS TELEPHONE NO. FAX NUMBER *If your organization is applying for access for the first time, an administrator must be chosen. This is an important role in your organization. To see the responsibilities of the administrator, visit the Board’s web site www.wcb.state.ny.us, click e-bizWCB, click on the business application you are interested in, and then click on Administrator’s Responsibilities. ORGANIZATION TYPE a. REQUIRED INFORMATION Employer UIER Number:______________________________ FEIN: _______________________ NYS License Number_________________________ The NYS License Number MUST be provided for EACH health care provider requesting Web Submission of Claim Forms and the health care provider MUST be authorized by the Board to treat workers’ compensation injuries. For information about how to obtain Board authorization, visit the Board’s web site at www.wcb.state.ny.us, and click on “Resources for Health Care Providers and Payors.” b. Health Care Provider c. Health Insurance Providers Board Assigned H Number: ___________________ d. Insurer/Self-Insurer Board Assigned W Number: ___________________ e. Licensed Rep/Attorney Board Assigned R Number: ____________________ f. Third Party Administrator (TPA) Board Assigned T Number: ___________________ g. Other Specify (e.g. Safety Group): ________________________________________________ FEIN: _______________________ FEIN: _______________________ If you have additional requests or comments, use Comment area on reverse. I state that the information provided on this form and on any attachments is correct. ____________________________________ ____________________________________ ______________________ Prepared By Title Date RETURN FORM TO: e-BIZ-1CL (7-04) NYS WORKERS’ COMPENSATION BOARD, E-BUSINESS WEB APPLICATIONS, ROOM 19 100 BROADWAY- MENANDS ALBANY, NY 12241 DO NOT SCAN SEE REVERSE American LegalNet, Inc. www.USCourtForms.com A. NEW/ADDITIONAL USER INFORMATION (If request is for more than 8 users, copy this side of the form as needed and attach all copies to completed original.) FIRST NAME LAST NAME FIRST NAME ORGANIZATION NAME ORGANIZATION NAME ADDRESS ADDRESS E-MAIL ADDRESS LAST NAME E-MAIL ADDRESS TELEPHONE NO. FAX NO. TELEPHONE NO. FAX NO. FIRST NAME LAST NAME FIRST NAME LAST NAME ORGANIZATION NAME ORGANIZATION NAME ADDRESS ADDRESS E-MAIL ADDRESS E-MAIL ADDRESS TELEPHONE NO. FAX NO. TELEPHONE NO. FAX NO. FIRST NAME LAST NAME FIRST NAME LAST NAME ORGANIZATION NAME ORGANIZATION NAME ADDRESS ADDRESS E-MAIL ADDRESS E-MAIL ADDRESS TELEPHONE NO. FAX NO. TELEPHONE NO. FAX NO. FIRST NAME LAST NAME FIRST NAME LAST NAME ORGANIZATION NAME ORGANIZATION NAME ADDRESS ADDRESS E-MAIL ADDRESS E-MAIL ADDRESS TELEPHONE NO. FAX NO. TELEPHONE NO. FAX NO. C. COMMENTS-Attach additional pages as needed. e-BIZ-1CL (7-04) DO NOT SCAN American LegalNet, Inc. www.USCourtForms.com