Oregon
Workers Comp
Proof Of Coverage - Insurer
Last updated: 5/23/2024
Oregon Proof of Coverage EDI Insurer Profile {4821}
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Description
Form 4821 - OREGON PROOF OF COVERAGE EDI INSURER PROFILE. 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. www.FormsWorkflow.com
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