Electronic Trading Partner Agreement Form


VWC requires the completion of an Electronic Partnering Agreement to use Electronic Data Interchange (EDI) technologies and techniques to meet VWC Workers’ Compensation reporting requirements. This document is an agreement between the parties (the Claim Administrators submitting the EDI transactions and the Commission) for the purpose of transmitting Workers’ Compensation Claims Related Data to the VWC.

Instructions: 

This document must be fully completed in order for your organization to be approved for production in Virginia. Please complete each of the following sections:

  1. Please list the legal name of the entity submitting the EDI Transactions to VA.
  2. This section should already be completed but if it is not, you must check both First Report of Injury and Subsequent Report of Injury
  3. Nothing needed except your review of the information listed.
  4. Nothing needed except your review of the information listed.
  5. Nothing needed except your review of the information listed.
  6. Nothing needed except your review of the information listed.
  7. Nothing needed except your review of the information listed.

Please date the document with the date it is completed and complete the section under For the Reporter. The Commission will review all of your Trading Partner Document and once you are approved for production in Virginia, we will complete the For the Jurisdiction section and return a copy of the signed agreement to you for your records.