eClaims Inquiry Trading Partner Registration

State of New York - Workers' Compensation Board

THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.

Required items are indicated by an *.

Registration For
Trading Partner
Contacts
Administrator

Registration For

* This Registration is for:

Insurance Carrier/Self-Insured Employer
Third Party Administrator (TPA)

Trading Partner Information

* Third Party Administrator Legal Name:

* Insurer Legal Name:

* Board assigned W Number (Carrier Code Number):

* Board Assigned T Number:

Business Mailing Address

* Address Line1:

Line 2:

* City: State: Zip Code: Country:

eClaims Inquiry User Information

*First Name: *Last Name:

*Email Address:

*Area Code: *Phone Number: Ext:

*Address Line 1:

Line 2:

*City: State: Zip Code: Country:

Designated Administrator Information

The designated administrator will be provided a user ID and password to access an online eClaims Administrator web application to request or remove employee access to eClaims Inquiry.

* First Name:

* Last Name:

* e-mail Address:

* Area Code: * Phone Number: ext.

* Address Line1:

Line 2:

* City:

*State: Zip Code: Country:

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Online Registration

State of New York - Workers' Compensation Board

Business Mailing Address

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