EDI Trading Partner Profile (For FROI And SROI) {E7}

EDIEDI TR TRADADIINNG G PP AARRTTNNEER PRR PROOFFIILLEE Reporting Purpose Code PARTN ER TPA 9 Carrier 9 Service Bureau 9 Jurisdiction 9 Employer 9 Other 9 Sender Administrator 9 TRADING PARTNER: Name : FEIN: Mail/Address: City: State: Postal Code: Contact Person: Phone: Fax #: FILE TRANSMISSION : FILE TYPE : 148 9 (FROI) POC 9 Paper 9 Flat File 9 A49 9 (Sub. Report) Medical 9 Other 9 ANSI 9 DAY OF WEEK: FREQUENCY O F REPORTING : Weekly 9 Mon thly 9 Semi-Annually 9 Sat . 9 Sun. 9 Mon. 9 Daily 9 Bi-weekly 9 Quarterly 9 Annually 9 Tue. 9 Wed.9 Thu r. 9 Fri.9 NETWORK: Production 9 S tart Date MAIL BOX ACCT. ID: USER ID: Test 9 S tart D ate M ESSAGE CLASS: ORGANIZATIO NS REPORTING UNDER SENDER ADMINIS TRATOR: Claim Administrator N ame FEIN Type Postal Code AAggrreemeemenentt P Peerrssoonn TiTittllee SSiigngnaattuurree DaDattee WCA E7/10/13/95