Free F207-193-000 Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form - Washington

MAIL COMPLETED FORM TO:
Department of Labor and Industries Self Insurance Section / SIEDRS Enrollment PO Box 44890 Olympia, WA 98504-4890 Fax: (360) 902-6977 E-mail: [email protected]

Self-Insurance Electronic Data Reporting System (SIEDRS)

Enrollment Form

Check one: 1. Submitter (includes TPAs and self-administered employers) 2. Account ID:
(For all employers. TPAs do not complete)

Non-submitting employer

3. Company Name: 4. Mailing Address: (Street or PO Box) City 5. Contact Name: State ZIP

6. Contact Phone Number: (Include area code)

7. E-mail address (may be a shared mailbox): 8. Data will be submitted by:
(For non-submitting employers only. TPAs and self-administered employers do not complete)

9. COMMUNICATION OPTIONS 9a. and 9b. Non-submitting employers select from the following communication options:
(SUBMITTERS WILL AUTOMATICALLY RECEIVE THESE COMMUNICATIONS)

9a. E-mail notification options Each time my data is processed When corrections are overdue When a monthly file is overdue

9b. Error reporting options Report of errors for each file posted Report of overdue corrections

9c. Both submitters and employers select from the following options: Quarterly Activity Report containing counts of data submitted and accepted Quarterly Error Summary Report containing error counts Are you willing to share your SIEDRS experience with others? Check here if we can share your contact information with other self-insurance community members. 10. Participation Agreement Statement My company agrees to the participation requirements documented in the SIEDRS Enrollment Package.
SIEDRS Contact and Company name (print)

Contact person's signature F207-193-000 Self-Insurance (SIEDRS) Enrollment Form 02-2008

Date

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SIEDRS
(Self-Insurance Electronic Data Reporting System) Enrollment Form Instructions
1. Check the "Submitter" box if you will be submitting data directly to SIEDRS (this includes TPAs and self-administered employers). Check the "Non-submitting employer" box if you are a self-insured employer and someone else will be submitting data on your behalf. All self-insured employers must complete "Account ID". TPAs should leave this line blank. The name of the company enrolling. The complete mailing address of the company enrolling. Any SIEDRS communications sent by mail will be sent to the address provided here. The name of your company's primary contact for all SIEDRS issues. The phone number where your SIEDRS contact person can be reached. Provide one e-mail address for SIEDRS communications. All e-mail generated by SIEDRS will be sent to this e-mail address. A shared mailbox is acceptable. Non-submitting employers: Provide the name of the TPA or company that will be submitting data on your behalf. (That company must also complete an enrollment form.) Submitters: Leave this line blank. Communication options: Sections 9a and 9b list communications that are optional for non-submitting employers. Submitters will automatically receive these communications and cannot "opt out". Section 9a, E-mail notifications: Check the first box if you want to receive a confirmation e-mail every time SIEDRS processes your data. Check the second box if you want an e-mail when errors in your data have not been corrected within the expected time frame. Check the third box if you want an e-mail when it has been more than a month since data was submitted on your behalf. Section 9b, Error reports: Check the first box if you wish to receive detailed error reports (if any) every time SIEDRS processes your data. Check the second box if you wish to receive reports identifying specific errors for which corrections are overdue. Section 9c describes summary level reports that are optional for both submitters and nonsubmitting employers. Check the first box if you wish to receive a quarterly summary showing reporting activity, i.e. the number of files, claims, and data elements submitted during each quarter, the number of errors, etc. Check the second box if you wish to receive a report of error counts for each quarter. Questions? Call (360) 902-6748 or e-mail [email protected]

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F207-193-000 Self-Insurance (SIEDRS) Enrollment Form 02-2008