eClaims Trading Partner Registration

Registration For

* This Registration is for:

Insurance Carrier/Self-Insured Employer
Insurance Group (Defined by the NYS Insurance Dept. and contains two or more insurance companies.)
Third Party Administrator (TPA)
Vendor

Trading Partner Information

* 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:

The Sender ID (FEIN) is the Federal Employer's Identification Number of your business entity. This, along with the 9-digit Postal Code (Zip + 4), will be used to identify a unique trading partner. For FTP Trading Partners, the Sender ID FEIN and Postal Code should be the same as those that will be used by the Trading Partner as the SENDER ID in the Header Record of all flat file EDI transmissions from the partner.

Sender Identification

* Sender ID (FEIN) :

* Sender Postal Code:

Contacts Information

Provide contact information for: Executive Officer (someone who is authorized to execute contracts), Business Contact, Technical Contact, and the person preparing this registration. The Board will e-mail the Executive Officer a Trading Partner Agreement to be completed and returned to the Board before the Trading Partner can begin submitting eClaims data to the Board.

* First Name	* Last Name	* Email	*Area Code	* Phone	Ext.	* Contact Type
Contact's First Name	Contact's Last Name	Contact's Email Address	Contact's Area Code	Contact's Phone Number	Contact's Phone Extension	Executive Officer Business Contact Technical Contact Preparer

Administrator Information

The Trading Partner must designate an Administrator. This person will be provided a user ID and password to access an online web application to provide the initial information required to create sender associations (i.e. insurers, Third Party Administrators, vendors) and to keep the Trading Partner's information up-to-date. For more information on Trading Partner registration requirements and relationships please visit the eClaims Registration Overview web page.

The administrator will use the online web application to:

Keep Contact information updated for all methods of submission, web and FTP.
Identify Third Party Administrators whose claims data the Trading Partner (Sender) will be submitting.
Add or remove Insurers whose claims data the Trading Partner (Sender) will be submitting.
Request or remove employee access to web data entry of the Trading Partner's claims.
Designate a vendor to submit the Trading Partner's claims data via flat file EDI transmissions.
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:

Trading Partner's Insurer ID List

Provide the Insurer FEIN, Legal Name and Board assigned W Number (carrier code number) for all insurers whose claims will be electronically filed (by Vendor FTP, FTP, or web) to the Board. The Board will notify the registering party of any discrepancy between the information in this registration and the Board's present records. The information submitted in this registration will be used during the validation process, for data submissions, where the Insurer FEIN is the primary identifying key. It is understood that this list will have entries added or removed from time to time; those changes will be reported by the Trading Partner's designated Administrator.

Insurer FEIN	Insurer / Self-Insured Employer Legal Name	Board assigned W Number
Carrier's FEIN	Carrier's Name	Carrier's Code #

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Online Registration

State of New York - Workers' Compensation Board

Business Mailing Address

Sender Identification

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