The Commission requires completion of this formas part of your agreement with the VWC to submit EDI transactions to Virginia. This form provides the Commission each Claim Administrator Name and Federal Employer Identification Number (FEIN) that your organization may submit EDI transactions for as well as a point of contact and address information for each of your offices.
This formmust be fully completed in order for your organization to be approved for production in Virginia. The form must include the FEIN, legal name and postal code of the sender on the top part of the form. In the spaces provided, please provide:
- The FEIN and legal name of the Claim Administrator that will be administering VWC claims
- Name of Claim Representative contact person that could answer questions or could direct VWC to the appropriate adjustor for the claim
- Phone number of the Claim Representative contact person that could answer questions or could direct VWC to the appropriate adjustor for the claim
- Physical street address, city, state and nine digit postal code related to the Alternate Postal Code that will be sent in the First Report of Injury transaction (FROI) for each Claim Administrator. Please be sure that the four digit extension on the postal code relates to the physical address, not the mailing address.
This form may be filed with the Commission in the following ways:
- EMAIL: Email the completed forms to firstname.lastname@example.org. Please add “Trading Partner Documents” as the subject.
- FAX: Fax the complete form to 804-418-4919 with Attention: EDI QA Department
- MAIL: Mail the completed form to 333 E. Franklin St., Richmond, VA 23219 with Attention: EDI QA Department
For questions, please contact the Commission toll-free at 1-877-664-2566 and ask for the EDI QA Department or by email at email@example.com.