The Commission requires completion of this document as part of your agreement with the VWC to submit EDI transactions to Virginia. This document 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 document must 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.