Montana > Workers Compensation
Trading Partner Profile (EDI) - Montana
| Trading Partner Profile (EDI) Form. This is a Montana form and can be used in Workers Compensation . |
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Trading Partner Profile Trading Partner Type: ____Service Bureau ____Claims Administrator ____Employer ____Other (specify): _____________ Master Trading Partner Information: Name: ________________________________________ Master FEIN: ________________________________________ Physical Address: ________________________________________ City: ________________________________________ State: _____________________ Postal Code: ______ Mail Address: ________________________________________ City: ________________________________________ State: __________________ Postal Code: ______ Contact Information: Business Contact: Technical Contact: Name: _________________________ Name: _________________________ Title: __________________________ Title: __________________________ Phone: _________________________ Phone: _________________________ FAX: __________________________ FAX: __________________________ E-mail: ________________________ E-mail: _________________________
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