Oregon Proof of Coverage EDI Insurer Profile
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Oregon Proof of Coverage EDI Insurer Profile Form. This is a Oregon form and can be use in Proof Of Coverage - Insurer Workers Comp.
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Tags: Oregon Proof of Coverage EDI Insurer Profile, 4821, Oregon Workers Comp, Proof Of Coverage - Insurer
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 behalf of the insurer listed
above:
Vendor name
Vendor FEIN
Contact information for EDI proof-of-coverage business contact:
Business contact name
Address
Title
City
E-mail address
State
ZIP
Phone
Contact information for EDI proof-of-coverage technical contact:
Technical contact name
Address
Title
City
E-mail address
State
ZIP
Phone
Contact information for person who prepared profile information, if different from above:
Name
Address
Title
City
E-mail address
State
ZIP
Phone
Authorized signature
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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