Trading Partner Agreement Filing Guaranty Contracts Through Electronic Data Interchange Workers’ Compensation Division The director of the Department of Consumer and Business Services through the Workers’ Compensation Divison agrees to accept, and (Insurer) agrees to report IAIABC proof-of-coverage information via electronic data interchange (EDI). This agreement is lawful and performance under this agreement constitutes complete performance of the parties under Oregon laws pertaining to the execution of guaranty contracts by the parties. This agreement shall become effective , and shall remain in effect until either party terminates as provided in paragraph 11. This agreement shall apply to all proof-of-coverage transactions establishing guaranty contracts for each employer reported during the effective period of the agreement. 1. The purpose of this agreement is to initiate, implement, and facilitate the Insurer’s filing of a guaranty contract via EDI with the director consistent with this agreement, Chapter 656 of the Oregon Revised Statutes, and Chapter 436, Division 162 of the Oregon Administrative Rules. The Insurer may contract with a vendor at any one time to act as its agent for the purposes of transmitting proof-of-coverage transactions via EDI. The Insurer shall complete a new Oregon Proof of Coverage EDI Insurer Profile (Form 4821), when contracting with a vendor to transmit proof of coverage on its behalf. The Insurer shall remain responsible for complying with all guaranty contract legal requirements and for all electronic records submitted by the Insurer or its vendor. 2. The Insurer is responsible for submitting, or contracting with an approved vendor to submit on its behalf, proof-ofcoverage data in the IAIABC Release 2.1 Flat File Format to the director. The director and the sender of data may modify transmission times and frequencies as needed to accommodate business needs. 3. The Insurer agrees to assume, without monetary limit, the liability of each employer reported via EDI by the Insurer or its vendor, arising during the period the guaranty contract is in effect, for prompt payment of all compensation for compensable injuries that may become due under Chapter 656 of the Oregon Revised Statutes to subject workers and their beneficiaries. A legally distinct employer shall be determined by each unique federal employer identification number (FEIN) reported by the Insurer or its vendor in the Insured and/or Employer Record sets of a Proof of Coverage Establishing Document Transaction as provided in OAR 436-162-0350. 4. The authorized signature of the Insurer on this agreement is understood and agreed to satisfy the requirements of 656.419 and OAR 436-050-0060 that each individual guaranty contract be signed by an authorized representative of the Insurer. 5. The FEIN of the Insurer on each proof-of-coverage or guaranty contract is recognized as the insurer’s electronic signature and it satisfies the requirements cited above that each guaranty contract be signed by an authorized representative of the insurer. 6. The Insurer agrees to pay any and all costs it incurs and costs associated with reporting and filing data to the director via EDI. The director agrees to pay any and all costs associated with any transmission to the Insurer or their vendor identified in Form 4821. 7. The director’s Employer Data System is the designated information processing system for proof-of-coverage transmissions containing Insured and Employer Records sets that create a guaranty contract under this agreement and OAR 436-162. Mandatory or conditional data elements that are omitted or are in illogical format are not capable of being processed by the designated information processing system, and will be rejected. 440-4820 (1/11/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com 8. Electronic acknowledgements of transactions accepted or rejected will be provided by the division to the sender of the EDI data within five (5) business days, unless system problems temporarily prevent the generation of acknowledgements. 9. Form 4821- Oregon Proof of Coverage EDI Insurer Profile, is annexed and incorporated into this agreement. 10. The Oregon EDI Implementation Guide for Proof of Coverage is annexed and incorporated into this agreement. 11. The parties may mutually agree to change the terms of the agreement by written instrument. It is the director’s intention that any changes necessary due to the Workers’ Compensation Division’s business needs be worked out for the mutual benefit of the director and the Insurer. The director may not alter the terms of this agreement to implement a business need, or state or federal law or regulation, without providing the Insurer at least 30 days notice. If state or federal law does not allow the director to provide 30 days notice to Insurer, the law will determine when a change to this agreement is effective. Either party may terminate this agreement with 30 days notice to the other. 12. If applicable, words and phrases contained in this agreement shall have the same meaning as definitions provided by OAR 436-162-0005 and 436-162-0300. SIGNED: Authorized insurer representative Date Print name: Department of Consumer and Business Services By: John Shilts, WCD administrator Date Attach signed Form 4821 and fax to 503-947-7514, Attn: WCD EDI coordinator 440-4820 (1/11/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com