Free E8.PDF - New Mexico


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Pages: 2
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State: New Mexico
Category: Workers Compensation
Author: lrollman
Word Count: 641 Words, 4,203 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://workerscomp.state.nm.us/pdf/e8.pdf

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NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION INSURER/ADMINISTRATOR PROFILE REPORT
2410 CENTRE AVE. SE ? PO BOX 27198 ALBUQUERQUE, NM 87125-7198
PLEASE PRINT IN BLACK INK OR TYPE
REPORTING TYPE INSURER POC INSURER CLAIMS NAME OF INSURER ADMINISTRATOR SENDER/VENDOR REPORTING PURPOSE INITIAL CHANGE DELETE WCA ID NUMBER REPLACE DATE OF REPORT
OFFICIAL USE ONLY

CHECK IF APPOPRIATE SELF-INSURANCE

INSURED FEDERAL ID NUMBER

CONTACT PERSON

PHONE NUMBER

ADDRESS

CITY

STATE

ZIP

PHONE

EMAIL

MAILING ADDRESS (IF DIFFERENT)

CITY

STATE

ZIP

PHONE

EMAIL

SENDER/VENDOR

SENDER/VENDOR FEDERAL ID NUMBER

CONTACT PERSON

PHONE NUMBER

ADDRESS

CITY

STATE

ZIP

PHONE

E-MAIL

EDI CLAIMS FIRST REPORT OF INJURY OR ILLNESS EDI CLAIMS NOTICE OF BENEFIT PAYMENT CLAIM ADMINISTRATOR

WEB PAGE TRANSMISSION OF FIRST REPORT OF INJURY OR ILLNESS WEB PAGE TRANSMISSION OF NOTICE OF BENEFIT PAYMENT CLAIM ADMIN. FEDERAL ID NUMBER

POC - WEB POC - EDI

CONTACT PERSON

PHONE NUMBER

ADDRESS

CITY

STATE

ZIP

PHONE

E-MAIL

Form WCA E8.1 (7/00) Purpose of Report: The Insurer/Administrator Profile Report is used for maintaining information on insurance carriers, self-insured employers, and claims administrators that pay workers'compensation claims or provide financial coverage of workers'compensation liability to employers in the state. This information is used to send out important rule changes or other correspondence to necessary parties. Filing Instructions: For carriers or self-insured groups providing workers'compensation coverage to employers, the insurer will complete the reporting type as insurer POC (Proof Of Coverage), complete the Reporting Purpose, Date Of Report, WCA ID Number if known, and complete the block of information for the insurer that identifies the Sender/Vendor for EDI POC. This report should be updated with changes within 30 days of those changes. For carriers, self-insureds, and claims administrators providing claims administration and data reporting to the WCA, the form must be completed based on the boxes checked in the reporting type block. Note: if you are sending claims data via EDI, the sender must also complete the trading partner profile form. All changes or initial reports must be submitted within 30 days of the action. The WCA ID NUMBER and other information concerning submission of this form may be obtained from the Economic Research Bureau, please call (505) 841-6072. If you the carrier, claims administrator or self-insured group have a vendor sending POC or claims data to the administrator, the sender is required to complete this form in your behalf.

Definitions: Reporting Type: This indicates who is submitting the report to the WCA. If the sender of the carrier or self-insured group is reporting POC data, then the boxes indicating Insurer POC and Sender/Vendor would be checked. If the sender is reporting claims data to the WCA, the sender would indicate both the Insurer Claims and Sender/Vendor boxes. Note: it is possible that the sender is both the claims administrator and the sender. In this case all three boxes would be indicated (Insurer Claims, Administrator and Sender/Vendor). Reporting Purpose: The reporting purpose indicates the reason the report is being sent to the WCA. Date of Report: The date of the reporting action. INSURER BLOCK: For both the Insurer POC and Insurer Claims Reporting Type, the Name, Federal Identification Number (FEIN), Contact Person, Phone Number, Location and Mailing Address must be completed. E-mails are optional, but would assist us in providing up-to-date information in the future. SENDER/VENDOR BLOCK: All of the Name, Federal Identification Number, and Mailing Address information is required. If the sender is sending EDI, then an e-mail address with contact information is also required. CLAIMS ADMINISTRATOR BLOCK: If a Claims Administrator handling claims is different than the Insurer, then the Name, Federal Identification Number, Contact Person and Mailing Address must be completed. An E-mail address is also required for EDI. Mailing Address: New Mexico Workers'Compensation Administration Statistical Reporting Section P.O. Box 27198 Albuquerque, NM 87125-7198