Oregon Form 4821 – Fill Out and Use This PDF

Oregon Form 4821 PDF Details

In the realm of workers’ compensation in Oregon, the Form 4821 serves as a crucial document for insurers, facilitating the submission of proof-of-coverage data to the department via electronic data interchange (EDI). This form, known officially as the Oregon Proof of Coverage EDI Insurer Profile under the Workers’ Compensation Division, must be completed by insurers or their authorized vendors prior to transmitting any proof-of-coverage information electronically. It mandates the provision of detailed information about the insurer, including the name and Federal Employer Identification Number (FEIN), and similarly details for any vendor authorized to submit data on the insurer’s behalf. Furthermore, the form requires contact details for both the business and technical contacts involved in the EDI proof-of-coverage process, as well as for the person who prepared the profile, if different. Essential for ensuring that each subsidiary insurer within an insurance group is individually accounted for, the form requires a separate submission for each, provided they are licensed to write workers’ compensation insurance in Oregon. The design of this form underscores the commitment of the Workers’ Compensation Division to streamline and secure the process of managing workers’ compensation insurance through modern technological means, offering a structured format for the accurate and efficient exchange of vital coverage information.