NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION
EDI TRADING PARTNER PROFILE
ATTN: STATISTICS PO BOX 27198 ALBUQUERQUE, NM 87125-7198
PLEASE PRINT IN BLACK INK OR TYPE
Reporting Purpose Code
PARTNER TYPE:
TPA Employer
Carrier Other
Service Bureau
Jurisdiction
Sender Administrator
TRADING PARTNER: Name: Mail/Address: City: Postal Code: Contact Person: Fax #: Phone: State: FEIN:
A49 (Sub. Report) Medical FREQUENCY OF REPORTING: Weekly Daily Bi-weekly
FILE TRANSMISSION: 148 (FROI)
Other Monthly Quarterly
POC
FILE TYPE:
ANSI
Flat File
Semi-Annually
Annually
DAY OF WEEK:
Sat. Sun. Mon.
Tue. Wed. Thur. Fri.
NETWORK: Production MAIL BOX ACCT. ID: USER ID: MESSAGE CLASS:
ORGANIZATIONS REPORTING UNDER SENDER ADMINISTRATOR:
Start Date Start Date_______________
Test
Insurer Name
FEIN
Type
Postal Code
Agreement Person
Title
Signature
Date
FORM WCA E7.1 (7/00)