Blank Oregon 4821 Form

1. What is the purpose of the Oregon 4821 form?

   The Oregon 4821 form serves as a necessary step for insurers before they can submit or authorize a vendor to send proof-of-coverage data to the Workers’ Compensation Division through electronic data interchange (EDI). This ensures that all parties involved have the correct information and authorization in place.

2. Who needs to complete the Oregon 4821 form?

   Any insurer that is planning to report proof-of-coverage information electronically must complete this form. If an insurer is part of an insurance group with multiple subsidiaries, each subsidiary that is licensed to write workers’ compensation insurance in Oregon must submit a separate form.

3. What information is required on the form?

   The form requires several pieces of information:

   • Insurer name and FEIN (Federal Employer Identification Number)
   • Vendor name and FEIN if a vendor is authorized to submit data
   • Contact details for both business and technical contacts
   • Information about the person who prepared the profile
   • Authorized signature and date

4. How do I submit the Oregon 4821 form?

   You can submit the completed form either by fax or email. The fax number is 503-947-7514, and the email address is [email protected]. Make sure to keep a copy for your records.

5. What happens if I need to change the vendor?

   If there is a change in the vendor, you will need to complete a new Oregon 4821 form. Be sure to indicate that the new profile replaces the previous one by noting the date of the old profile.

6. Is there a deadline for submitting the Oregon 4821 form?

   While there is no specific deadline mentioned, it is crucial to submit the form as soon as possible to avoid any delays in processing proof-of-coverage data. Timely submission ensures compliance with state regulations and smooth operations.

7. What if I have questions while filling out the form?

   If you encounter any difficulties or have questions while completing the form, it is advisable to reach out to the Workers’ Compensation Division directly. They can provide guidance and ensure that you have the correct information.

8. What should I do after submitting the form?

   After submission, it is essential to follow up and confirm that the form has been received and processed. Keeping a record of your submission can help in case any issues arise later.

Filling out the Oregon 4821 form can be a straightforward process, but there are common mistakes that can lead to delays or complications. One frequent error is neglecting to provide the insurer name and FEIN accurately. This information is crucial for identifying the insurer and ensuring that the proof-of-coverage data is properly linked to the correct entity.

Another mistake often made is failing to specify the vendor name and FEIN if a vendor is authorized to submit data on behalf of the insurer. This section is essential for establishing who is responsible for submitting the electronic data interchange (EDI) proof-of-coverage. Omitting this information can result in confusion and potential rejections of the submission.

In addition, many individuals overlook the importance of providing complete contact information for both the business and technical contacts. Each section requires specific details, including names, titles, email addresses, and phone numbers. Incomplete or incorrect contact information can hinder communication and lead to delays in processing.

Another common oversight is not indicating the date the profile was prepared. This date is vital for record-keeping and tracking any updates or changes made to the profile. Failing to include this information can complicate future interactions with the Workers’ Compensation Division.

Some people also forget to sign the form. An authorized signature is required to validate the submission. Without it, the form may be considered incomplete, leading to further delays in processing.

Additionally, individuals may mistakenly use an outdated version of the form. It's important to ensure that the latest version is being used to avoid any compliance issues. Keeping track of updates can save time and prevent unnecessary complications.

Lastly, not returning the form to the correct address is a frequent mistake. The instructions specify that submissions should be sent either by fax or email to the WCD EDI Coordinator. Ensuring that the form reaches the right destination is crucial for timely processing.

By being mindful of these common mistakes, individuals can streamline the process of completing the Oregon 4821 form and help ensure that their submissions are processed efficiently.

The Oregon 4821 form is essential for insurers submitting proof-of-coverage data through electronic data interchange (EDI). Several other documents are often used in conjunction with this form to ensure compliance and facilitate communication between insurers and the Workers’ Compensation Division. Below is a list of related forms and documents commonly utilized in this context.

• Oregon 4820 Form: This form is used for submitting proof of coverage data directly to the Workers’ Compensation Division. It serves as the primary document for insurers reporting coverage information.
• Oregon 4822 Form: This document is required for insurers to report any changes in coverage status. It helps maintain accurate records with the Workers’ Compensation Division.
• Insurer License Application: Insurers must complete this application to obtain or renew their license to write workers’ compensation insurance in Oregon. It includes essential information about the insurer's operations.
• Vendor Authorization Form: This form authorizes a third-party vendor to submit EDI proof-of-coverage data on behalf of the insurer. It ensures that the vendor is recognized by the Workers’ Compensation Division.
• EDI Business Contact Information Form: This document collects detailed contact information for business representatives involved in EDI submissions. It is vital for communication regarding proof-of-coverage data.
• Technical Contact Information Form: Similar to the business contact form, this document gathers information for technical contacts responsible for EDI operations. It facilitates technical support and troubleshooting.
• Claims Reporting Form: This form is used to report workers’ compensation claims. It is crucial for tracking claims and ensuring compliance with state regulations.
• Proof of Coverage Certificate: Issued to employers, this certificate serves as evidence that they have the required workers’ compensation insurance coverage. It is often requested by regulatory agencies or other parties.
• Annual Reporting Form: Insurers must complete this form to provide annual updates on their operations and coverage statistics. It is essential for regulatory oversight and compliance.

These documents collectively support the process of managing workers' compensation insurance in Oregon. Proper use of these forms ensures compliance with state regulations and facilitates efficient communication between insurers and regulatory authorities.

The Oregon 4821 form serves a specific purpose in the context of workers' compensation insurance. Several other documents share similarities with it in terms of their function and the information they require. Below is a list of nine documents that are comparable to the Oregon 4821 form:

• California Proof of Coverage (Form 300) : This form is used by insurers in California to provide proof of coverage for workers' compensation insurance. Like the Oregon 4821, it requires insurer and vendor information, ensuring compliance with state regulations.
• Washington Workers’ Compensation Proof of Coverage : This document serves a similar purpose in Washington State, allowing insurers to report proof of coverage. It also mandates specific details about the insurer and the authorized vendor.
• New York Workers’ Compensation Board Form C-105.2 : This form is utilized in New York for proof of coverage. It includes sections for insurer identification and vendor authorization, paralleling the structure of the Oregon 4821.
• Texas Certificate of Insurance (Form 5-100) : In Texas, this certificate provides proof of workers' compensation coverage. It requires similar information regarding the insurer and the entity authorized to submit data.
• Florida Proof of Coverage (Form DWC-250) : This form is required for Florida insurers to demonstrate compliance with workers' compensation coverage. It also includes sections for insurer and vendor details.
• Illinois Workers’ Compensation Insurance Coverage Verification : This document is used to verify coverage in Illinois. Like the Oregon 4821, it requires information about the insurer and the vendor authorized to report data.
• Pennsylvania Workers’ Compensation Proof of Insurance : This form is essential for Pennsylvania insurers to provide proof of coverage. It includes similar requirements for insurer and vendor information.
• Ohio Bureau of Workers’ Compensation Certificate of Coverage : This certificate serves as proof of coverage in Ohio, requiring similar details about the insurer and the vendor authorized to submit proof.
• Massachusetts Workers’ Compensation Insurance Affidavit : This affidavit is used to confirm coverage in Massachusetts. It requires the same type of information regarding the insurer and the authorized vendor.

Each of these documents plays a crucial role in ensuring that workers' compensation coverage is properly reported and compliant with state regulations, similar to the Oregon 4821 form.

When filling out the Oregon 4821 form, it is important to follow specific guidelines to ensure accuracy and compliance. Here are some dos and don'ts to keep in mind:

• Do provide the correct insurer name and FEIN in the designated sections.
• Do authorize a vendor to submit proof-of-coverage data if applicable.
• Do include complete contact information for both business and technical contacts.
• Do ensure that a separate form is filled out for each subsidiary insurer.

• Don't leave any fields blank; all required information must be filled out.
• Don't forget to sign and date the form before submission.
• Don't use outdated information; make sure to replace any previous profiles as necessary.
• Don't submit the form without reviewing it for accuracy and completeness.

There are several misconceptions about the Oregon 4821 form that can lead to confusion. Here are four common misunderstandings:

• Only one form is needed for all insurers. Many believe that a single Oregon 4821 form can cover multiple insurers. In reality, a separate form is required for each subsidiary insurer within an insurance group that is licensed to write workers’ compensation insurance in Oregon.
• Insurers can submit the form after sending proof-of-coverage data. Some think they can send proof-of-coverage data first and then complete the form later. However, insurers must complete the Oregon 4821 form before submitting or authorizing a vendor to send proof-of-coverage data through electronic data interchange (EDI).
• The vendor must be a large company. There is a misconception that only large vendors can be authorized to submit EDI proof-of-coverage data. In fact, any vendor can be authorized as long as they meet the necessary requirements and the insurer completes the form correctly.
• Contact information is optional. Some people think that providing contact information on the form is not essential. However, accurate contact details for both business and technical contacts are crucial for effective communication regarding proof-of-coverage submissions.

When filling out and using the Oregon 4821 form, consider the following key points:

• Insurer Information: Clearly list the insurer's name and FEIN. This is essential for proper identification.
• Vendor Authorization: If a vendor will submit proof-of-coverage data, their name and FEIN must be included. Ensure that the vendor is authorized.
• Contact Details: Provide accurate contact information for both business and technical contacts. This facilitates communication regarding proof-of-coverage submissions.
• Separate Forms for Subsidiaries: Each subsidiary insurer in an insurance group needs its own form. Do not combine information from different subsidiaries.

Completing the form accurately and submitting it on time is crucial for compliance with Oregon's workers' compensation regulations.