Insurance Information

Select type of self insurance from the drop-down list. 

• Not Defined (select this option if the injured party is not self-insured)
• Individual
• Other Than Individual (i.e., business, corporation, organization, company, etc.)

Select Not Defined if the reportable event does not involve a self-insured Individual or other than an individual, such as businesses or organizations. 

If Individual is selected, the Policyholder's First Name and Last Name are required. If Other Than Individual is selected, Doing Business As (DBA) Name and/or Legal Name is required. 

Required if Self-Insured indicator is set to Yes.

Enter the Given/First Name of the policyholder or self-insured person associated with this insurance. 

First Name may contain only alpha characters and embedded spaces. Required only when the Self-Insured Type is Individual. 

Enter the Surname/Last Name of the policyholder or self-insured person associated with this insurance. 

Last Name can be comprised of letters, and embedded spaces, hyphens, or apostrophes. 

Required only when the Self-Insured Type is Individual.

Enter the Doing Business As name of self-insured organization/business. 

Required only when Self-Insured type is Other Than Individual and Legal Name is not provided. Provide at least two characters. 

Enter the Legal Name of self-insured organization or business. 

Required only when Self-Insured Type is Other Than Individual and DBA name is not provided. Provide at least two characters. 

Enter the insurer Federal Tax Identification Number assigned by the Internal Revenue Service (IRS) of the RRE reported in RRE Mailing Name field. Provide 9 digits including leading zero if applicable. Do not include dashes or spaces.

Required.

Note: For a foreign RRE without a valid IRS-assigned TIN, supply the pseudo-TIN created during Section 111 registration. 

Enter the unique RRE-defined identifier of the policy under which the claim was filed. Must contain at least three characters.

Notes:

If multiple RREs are submitting claims under the same policy number, enter this number consistently and in the same format.

Required except when insurance type is self insurance. However, if available, please provide this number on all new “add” records.

May be filled with zeros if you do not maintain a specific reference number.

If you are updating an existing claim that was previously accepted (i.e., the disposition is 01 or 02), this field will be disabled. If you need to correct the policy number on a previously submitted and accepted claim, you must delete the previously reported record and then submit a new claim with the correct policy number.

Enter the unique claim identifier by which the primary plan identifies the claim. 

Zeros are accepted for Liability and Worker’s Compensation Self-Insurance, if you do not have a specific claim number. 

Enter the name of the RRE that should be used to address correspondence relating to the associated claim. Provide at least two letters.

This field is pre-populated with the RRE information entered during registration but is open for editing.

Enter the primary mailing street address of the RRE reported in RRE Mailing Name field. 

This field is pre-populated with the RRE information entered during registration but is open for editing.

Required if "Foreign Country" state code not selected.

Enter the secondary mailing address of the RRE reported in RRE Mailing Name field.

This field is pre-populated with the RRE information entered during registration but is open for editing.

Optional. Leave blank if "Foreign Country" state code is selected.

Enter the city of the RRE reported in RRE Mailing Name field. 

This field is pre-populated with the RRE information entered during registration but is open for editing.

Required if "Foreign Country" state code not selected.

Enter the state of the RRE reported in RRE Mailing Name field. Select the state from the drop-down list. If the RRE does not have a U.S. mailing address, select "Foreign Country".

If "Foreign Country" is selected, leave other address fields blank. Enter the foreign address in the Foreign Address fields.

Enter the five-digit U.S. postal code plus ZIP+4 extension (optional) of the RRE reported in RRE Mailing Name field. 

Required if "Foreign Country" state code is selected.

Enter the name of the department for the plan contact.

Department Name may contain only alpha characters and embedded spaces. 

This name will be used for claim related informal communications and will not be used for recovery Demand Letters. 

Optional. 

Enter the Given/First Name of the contact person to which communications should be directed. First Name may contain only alpha characters and embedded spaces. 

Optional.

Enter the Surname/Last Name of the contact person to which communications should be directed. Surname can be comprised of letters, and embedded spaces, hyphens or apostrophes. 

Optional.

Enter the phone number and extension (optional) of the plan contact. Phone fields must contain numeric characters.

Note: Number will be validated if entered.

Optional.

Enter the name to be used on the recovery agent’s copy of recovery-related correspondence associated with the claim. Provide at least 2 letters. 

If recovery agent information is submitted, all recovery-related correspondence associated with claims submitted with the same TIN will be sent to both the RRE and the recovery agent.

Optional.

Enter the primary mailing street address of the recovery agent.

Required if recovery agent information is submitted.

Enter the secondary mailing street address of the recovery agent.

Optional.

Enter the city of the recovery agent’s address.

Required if recovery agent information is submitted.

Enter the state of the recovery agent’s address. Select the state from the drop‑down list.

Required if recovery agent information is submitted.

When Insurance type is No-Fault, provide the monetary limit of the policy. 

Numeric digits and decimal points are allowed. Do not include commas or a dollar sign. If no decimal point is included, 2 positions will be implied. Fill with all 9’s if there is no limit.

This field is disabled if the insurance type is Liability or Workers’ Compensation.

Enter the date on which the No-Fault dollar limit was reached. Only provide if the limit has been reached. Must be a valid date if supplied.

This field is disabled if the insurance type is Liability or Workers’ Compensation.