Free untitled - Florida

FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION

EDI TRADING PARTNER PROFILE
IMPORTANT: Complete all fields designated with an asterisk ( * ). Form will be returned if any required fields are missing. Return this page to: Date Receiver Name: Florida Department of Financial Services, Division of Workers' Compensation [email protected] or [email protected] E-mail:

TRADING PARTNER TYPE* (check all that apply):
__ Insurer __ Self-Insurer __ Service Co/Third Party Administrator __ Vendor (POC Only)

MASTER TRADING PARTNER INFORMATION: Sender Legal Name* (no abbreviations): Sender ID: The Federal Employer Identification Number of your business entity. This, along with your 9-digit Postal Code
(Zip+4), will be used to identify a unique trading partner. The Sender FEIN and Postal Code provided below should be the same FEIN and Postal Code that will be sent for the SENDER ID in the Header Record for your POC and Claims EDI transmissions.

Sender FEIN*: Physical Address/Office Location:
Address Line 1*: Address Line 2: City*:

Postal Code* (9 digits): {

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State*: {

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Postal Code*: {

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Mailing Address/Office Location:
Address Line 1*: Address Line 2: City*:

State*: {

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Postal Code*: {

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Contact Information:
First Report of Injury (FROI) Proof of Coverage (POC) Business Contact*: Name: Title: Phone: FAX: E-mail: Business Contact: Name: Title: Phone: FAX: E-mail: Subsequent Report of Injury (SROI)

Technical Contact*: Name: Title: Phone: FAX: E-mail: Preparer Information* Name: Title: Phone: FAX: E-mail:

Is the Master Trading Partner Address/Office Location provided above also an active claims office location at which workers' compensation claims will be handled/adjusted?_________* If yes, provide the Claims Manager and Penalty Contact information on Page 2 of this form.

Draft DFS-F5-DWC-EDI-1(10/01/2006)

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FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION

EDI TRADING PARTNER PROFILE
Claims Manager: Name: Title: Phone: FAX: E-mail: Penalty Contact: Name: Title: Phone: FAX: E-mail:

Note: The penalty contact should be the associate to whom the Division should direct electronic penalty correspondence as a result of noncompliance with filing and/or payment requirements set out in Chapter 440, F.S., and Administrative Rules 69L-3, 69L-6, 69L-24, and 69L-56, F.A.C.

INDIVIDUAL TRADING PARTNER OFFICE INFORMATION: Will addresses/office locations other than, or in addition to, the master trading partner address/office location be transmitting EDI filings? _____* If yes, complete the below address and contact information for each address/office location that will be sending EDI transactions to the Division. Include one sheet for each office location. Physical Address/Office Location: Address Line 1: Address Line 2: City:

State: {

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Postal Code: {

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Mailing Address/Office Location: Address Line 1: Address Line 2: City:

State: {

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Postal Code: {

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EDI Business Contact: Name: Title: Phone: FAX: E-mail: EDI Technical Contact: Name: Title: Phone: FAX: E-mail: Claims Manager: Name: Title: Phone: FAX: E-mail:

EDI Business Contact: Name: Title: Phone: FAX: E-mail: EDI Technical Contact: Name: Title: Phone: FAX: E-mail: Penalty Contact: Name: Title: Phone: FAX: E-mail:

Draft DFS-F5-DWC-EDI-1(10/01/2006)

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