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Free Oregon 4821 Form

The Oregon 4821 form is a document used by insurers to provide proof of coverage data through electronic data interchange (EDI) to the Workers’ Compensation Division. Insurers must fill out this form before submitting or authorizing a vendor to send proof-of-coverage information. Each subsidiary insurer within an insurance group licensed to write workers’ compensation insurance in Oregon requires a separate form.

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Content Overview

The Oregon 4821 form is a crucial document for insurers involved in workers’ compensation coverage in Oregon. This form must be completed before any insurer can submit or authorize a vendor to electronically send proof-of-coverage data to the Workers’ Compensation Division. It serves as a profile that captures essential information about the insurer, including the insurer's name and Federal Employer Identification Number (FEIN). Each subsidiary insurer within an insurance group must have its own form, ensuring accurate reporting for all entities licensed to provide workers’ compensation insurance in the state. Additionally, the form requires details about the authorized vendor responsible for submitting the electronic data, along with contact information for both business and technical representatives. This includes names, titles, email addresses, and phone numbers, making it easier for the department to reach out if necessary. The completion of this form is not just a formality; it is a vital step in maintaining compliance with state regulations. Insurers must ensure that the profile is accurate and submitted promptly to avoid any disruptions in coverage reporting.

Similar forms

The Oregon 4821 form is essential for insurers submitting proof-of-coverage data through electronic data interchange (EDI) for workers' compensation. Several other documents share similarities with this form, primarily in their purpose of ensuring compliance and facilitating communication between insurers and regulatory bodies. Here are eight documents that are comparable to the Oregon 4821 form:

California DWC Form 1: This form is used by California insurers to report workers' compensation coverage. Like the Oregon 4821, it requires detailed information about the insurer and the vendor authorized to submit data.
Florida DFS Form 4-2200: This document serves a similar function in Florida, allowing insurers to report coverage information. Both forms require the insurer's name, FEIN, and contact details for proper communication.
Texas DWC Form-81: In Texas, this form is used to provide proof of coverage. Like the Oregon 4821, it necessitates clear identification of the insurer and the vendor responsible for data submission.
Washington L&I Coverage Verification Form: This form verifies coverage in Washington state. Similar to the Oregon 4821, it includes sections for insurer and vendor information, ensuring accurate reporting.
New York C-105.2: This form is utilized in New York to document proof of workers' compensation coverage. Both forms require detailed contact information for the insurer and the vendor.
Illinois Certificate of Insurance: In Illinois, this certificate serves to confirm coverage. Like the Oregon 4821, it emphasizes the importance of accurate data submission to the state’s regulatory body.
Small Estate Affidavit: For individuals managing simpler estates, the small estate affidavit form solution streamlines the distribution process without lengthy probate proceedings.
Pennsylvania WC-1: This form is used in Pennsylvania for workers' compensation coverage reporting. It parallels the Oregon 4821 in its requirement for both insurer and vendor details.
Ohio BWC Certificate of Coverage: This document verifies coverage in Ohio. Similar to the Oregon 4821, it requires comprehensive information about the insurer and designated vendor for data reporting.

Understanding these documents can help ensure that insurers meet their reporting obligations effectively, fostering a smoother process for all parties involved.

Preview - Oregon 4821 Form

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 behalfof 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

Authorizedsignature

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)

Key takeaways

When filling out and using the Oregon 4821 form, keep these key takeaways in mind:

Understand the Purpose: This form is essential for insurers to authorize vendors to submit proof-of-coverage data electronically to the Workers’ Compensation Division.
Complete Information: Ensure that all required fields are filled out accurately, including the insurer's name, FEIN, and vendor details.
Separate Forms for Subsidiaries: If you are part of an insurance group with multiple subsidiaries, remember that each one requires its own form.
Contact Details Matter: Provide complete contact information for both business and technical contacts to facilitate smooth communication.
Submission Instructions: Submit the completed form to the WCD EDI Coordinator via fax or email, as specified in the instructions.

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File Details

Fact Name	Description
Purpose	The Oregon 4821 form is used to authorize vendors to submit proof-of-coverage data for workers’ compensation insurance through electronic data interchange (EDI).
Requirement	Insurers must complete this form before they can submit proof-of-coverage data or authorize a vendor to do so.
Subsidiary Insurers	A separate form is needed for each subsidiary insurer within an insurance group that is licensed to write workers’ compensation insurance in Oregon.
Contact Information	The form requires detailed contact information for both business and technical contacts related to EDI proof-of-coverage.
Governing Law	This form is governed by the Oregon Workers’ Compensation Division regulations.

Documents used along the form

The Oregon 4821 form is an essential document for insurers involved in workers' compensation coverage. It ensures that the necessary proof-of-coverage data is submitted correctly through electronic data interchange (EDI). Alongside this form, several other documents may be required to facilitate compliance and streamline the process. Below is a list of related forms and documents that are often utilized in conjunction with the Oregon 4821 form.

Oregon Workers' Compensation Claim Form (Form 801): This form is used by employees to report a workplace injury or illness to their employer and initiate the workers' compensation claim process.
Oregon Workers' Compensation Employer's Report of Injury (Form 822): Employers complete this form to report an employee's injury to the Oregon Workers' Compensation Division, providing essential details about the incident.
Oregon Workers' Compensation Medical Report (Form 827): This document is used by medical providers to report the treatment and progress of an injured employee, ensuring that all medical information is documented for claims processing.
Oregon Workers' Compensation Insurer's Notice of Acceptance (Form 827): Insurers use this form to formally accept a workers' compensation claim, detailing the benefits that will be provided to the injured worker.
Oregon Workers' Compensation Insurer's Notice of Denial (Form 828): This document is issued by insurers to inform an employee that their claim has been denied, including reasons for the denial.
Oregon Workers' Compensation Reimbursement Request Form: This form allows employers to request reimbursement for costs associated with workers' compensation claims, ensuring they are compensated for their expenses.
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Oregon Workers' Compensation Appeal Form: Employees can use this form to appeal a decision made regarding their workers' compensation claim, seeking a review of the determination.
Oregon Workers' Compensation Policy Renewal Application: Insurers must complete this application to renew their workers' compensation policy, ensuring continued compliance with state regulations.

Understanding these forms and their purposes can greatly assist in navigating the workers' compensation process in Oregon. Having the correct documentation ensures that both insurers and employees are well-informed and protected throughout the claims process.