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Free Oregon 4821 Form

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The Oregon 4821 form, known as the Proof of Coverage EDI Insurer Profile, plays a crucial role in the administration of workers' compensation insurance in the state of Oregon. This form must be completed by insurers prior to submitting or authorizing a vendor to transmit proof-of-coverage data to the Workers’ Compensation Division via electronic data interchange (EDI). It serves as a necessary step to ensure compliance with state regulations regarding workers' compensation coverage. Each insurer must provide specific details, including the insurer's name and Federal Employer Identification Number (FEIN), particularly if they are directly reporting proof-of-coverage information. Importantly, a separate form is required for each subsidiary insurer within an insurance group that holds a license to write workers' compensation insurance in Oregon. The form also mandates the identification of the authorized vendor responsible for submitting the EDI data, along with their FEIN. Furthermore, it collects contact information for both business and technical representatives involved in the proof-of-coverage process, ensuring clear lines of communication. The form concludes with a section for an authorized signature, indicating the completion date and any necessary updates to previous profiles. Proper submission of the Oregon 4821 form is essential for maintaining accurate records and facilitating the smooth operation of workers' compensation coverage in the state.

Common mistakes

  1. Neglecting to complete all required fields: Each section of the Oregon 4821 form must be filled out completely. Omitting any information can lead to delays or rejection of your submission.

  2. Using incorrect or outdated contact information: Ensure that the contact details provided for both the business and technical contacts are current. This helps in facilitating communication between the insurer and the Workers’ Compensation Division.

  3. Failing to specify the correct vendor: When authorizing a vendor to submit proof-of-coverage data, be sure to accurately list the vendor’s name and FEIN. Errors here can result in miscommunication and processing issues.

  4. Not providing a separate form for each subsidiary: If your insurance group has multiple subsidiary insurers, remember that each one requires its own completed Oregon 4821 form. Failing to do so can complicate your coverage reporting.

  5. Ignoring the signature requirement: The form must be signed by an authorized individual. A missing signature can render the submission invalid, so ensure this step is not overlooked.

  6. Neglecting to update the profile date: When replacing an existing profile, it is crucial to indicate the date of the new profile. This helps maintain accurate records and avoids confusion.

  7. Forgetting to include the FEIN: The Federal Employer Identification Number (FEIN) is essential for identification purposes. Ensure that this number is correctly entered for both the insurer and the vendor.

  8. Submitting the form through the wrong channel: Pay attention to the submission instructions. The form should be sent to the specified fax number or email address to ensure it reaches the correct department.

  9. Overlooking the need for a technical contact: Providing contact information for a technical representative is important. This person can assist with any EDI-related issues that may arise during the submission process.

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Listed Questions and Answers

What is the purpose of the Oregon 4821 form?

The Oregon 4821 form serves as a Proof of Coverage EDI Insurer Profile for the Workers’ Compensation Division. Insurers must complete this form to authorize a vendor to submit proof-of-coverage data electronically to the department. This ensures that the information is accurately reported and complies with state regulations.

Who needs to complete the Oregon 4821 form?

Any insurer that intends to report proof-of-coverage information through electronic data interchange (EDI) must fill out this form. Each subsidiary insurer within an insurance group that is licensed to write workers’ compensation insurance in Oregon must complete a separate form. This requirement helps maintain clear records for each entity involved.

What information is required on the form?

The form requires several key pieces of information:

  1. Insurer name and FEIN (Federal Employer Identification Number).
  2. Vendor name and FEIN if a vendor is authorized to submit data.
  3. Contact information for both the business and technical contacts, including names, titles, email addresses, and phone numbers.
  4. The name and contact information of the person who prepared the profile, if different from the above contacts.
  5. An authorized signature and the date the profile was prepared.

How should the completed form be submitted?

Once the Oregon 4821 form is completed, it must be returned to the Workers’ Compensation Division EDI Coordinator. Insurers can submit the form either by fax at 503-947-7514 or via email at edinews.wcd@state.or.us. Timely submission is crucial to ensure compliance with reporting requirements.

What happens if there is a change in the vendor?

If there is a change in the vendor authorized to submit proof-of-coverage data, a new Oregon 4821 form must be completed. The new form should indicate that it replaces the previous profile. This ensures that the department has the most current information regarding who is authorized to report on behalf of the insurer.

Is there a deadline for submitting the Oregon 4821 form?

While the form itself does not specify a strict deadline, it is essential for insurers to submit it promptly to avoid delays in reporting proof-of-coverage data. Insurers should be aware of any specific timelines set by the Workers’ Compensation Division to ensure compliance with reporting obligations.

Form Specifications

Fact Name Description
Purpose The Oregon 4821 form is used to authorize vendors to submit proof-of-coverage data electronically for workers' compensation insurance.
Governing Law This form is governed by Oregon's workers' compensation laws, specifically ORS 656.726.
Insurer Requirement Insurers must complete this form before submitting proof-of-coverage data through electronic data interchange (EDI).
Subsidiary Insurers A separate form is required for each subsidiary insurer within an insurance group licensed in Oregon.
Contact Information The form requires contact details for both business and technical contacts related to EDI proof-of-coverage.
Submission Method Completed forms must be returned to the WCD EDI Coordinator via fax or email.
Signature Requirement An authorized signature is needed on the form to validate the information provided.
Profile Update The form allows for updates to the profile and indicates if it replaces a previous profile.