Oregon Proof of Coverage EDI Insurer Profile {4821}

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 Title E-mail address Address City State ZIP Phone Contact information for EDI proof-of-coverage technical contact: Technical contact name Title E-mail address Address City State ZIP Phone Contact information for person who prepared profile information, if different from above: Name Title E-mail address Address City 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) American LegalNet, Inc. www.FormsWorkflow.com