Insurer Contact Update {5188}

Insurer Contact Update IMPORTANT: The insurer must notify the Oregon Workers222 Compensation Division at least 30 days before the effective date of a change in contact information. See OAR 436-050-0110 (insurers) and OAR 436-050-0210 (self- insured employe rs) for more details on contact requirements. NOTE: Submit contact upd ates per insurer, not per group. Insurer Information Insurer222s full name: FEIN: Group name: NAIC: Required Contact Information Headquarters (HQ): Contact person: Phone: Email: Fax: Street address: Mailing address: City: State: ZIP: Payments and Collection (PAC) : Contact person: Phone: Ema il: Fax: Street address: Mailing address: City: State: ZIP: Coverage Processing (CVGC): Contact person: Phone: Email: Fax: Street address: Mailing address: City: State: ZIP: Claim Referral Information (CRI): Contact person: Phone: Email: Fax: Street address: Mailing address: City: State: ZIP: 440 - 5188 (2 /17/DCBS/WCD/WEB) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Optional Contact Information C laims Processing (CLM): Contact person: Phone: Email: Fax: Stree t address: Mailing address: City: State: ZIP: Premium Assessment (PADS): Contact person: Phone: Email: Fax: Street address: Mailing address: City: State: ZIP: Quarterly Claim Processing Performance (QCPP): Contact person: Phone: Email: Fax: Street address: Mailing address: City: State: ZIP: Electronic Data Interchange 226 proof of coverage filing (EDIP): Contact person: Phone: Email: Fax: Street address: Mailing address: City: State: ZIP: Electronic Data Interchange 226 medical billing (EDIM): Contact person: Phone: Email: Fax: Street address: Mailing address: City: State: ZIP: 440 - 5188 (2 /17/DCBS/WCD/WEB) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com If you have questions, contact insurer registration, Workers222 Compensation D ivision, at 503 - 947 - 7603 or 503 - 947 - 7705 . Mail this form to: OR Workers222 Compensation Division Attn: Insurer Registration P.O. Box 14480 Salem, OR 97309 - 0405 Or f ax it to: 503 - 947 - 7725 Or e mail it to: ins urerregistration.wcd@oregon.gov Insurer r epresenta t ive completing form: Name: Title: Date: Phone: Fax: E mail: For department use WCD number: Date received: Initials: Date processed: 440 - 5188 ( 2 / 17 /DCBS/WCD/WEB) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com