Senders Trading Partner Profile {WC170}

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION SENDER'S TRADING PARTNER PROFILE Date Trading Partner Type Jurisdiction Carrier Self Insured Employer Trading Partner FEIN Name Address City Mailing Address (if different) State Postal Code Service Bureau Third Party Administrator Other (please specify) City Contact Information Business Contact Name Title Phone Fax E-mail Mailing Address Business Contact Name Title Phone Fax E-mail Mailing Address Business Contact Name Title Phone Fax E-mail Mailing Address State Postal Code Technical Contact Name Title Phone Fax E-mail Mailing Address Technical Contact Name Title Phone Fax E-mail Mailing Address Technical Contact Name Title Phone Fax E-mail Mailing Address WC170 05/05 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS / DEFINITIONS This form is used to communicate the Sender's contact information. Colorado Department of Workers' Compensation (DOWC) is responsible for providing contact information on the Receiver form. The completed forms are exchanged between the Receiver and Sender. Date Trading Partner Type Trading Partner FEIN Enter the date the Trading Partner Profile is completed by the Sender. Check the appropriate category reflecting the Sender's business type. If other, please specify. This section provides identifying information about the Master Trading Partner. Enter the Federal Employer Identification Number (FEIN) of the Trading Partner that will transmit workers' compensation data. This must match the FEIN supplied on the entity's "Transmission Profile" form. This, along with the 9-digit postal code (Zip+4) in the Trading Partner address field, will be used to identify a unique Sender. Enter the name of your business entity corresponding with the FEIN that will be transmitting detailed workers' compensation information to DOWC. This must match the Name supplied on the entity's "Transmission Profile" form. Enter the street address of the physical location of your business entity. It will represent where materials may be received regarding this Sender if using a delivery service other then the U.S. Postal Service. Enter the city portion of the street address of your business entity. Enter the two (2) character standard state abbreviation of the state portion of the street address of your business entity. Enter the nine (9) digit postal code of the street address of your business entity. This field, along with Trading Partner FEIN will be used to uniquely identify a Trading Partner. This must match the postal code supplied on the entity's "Transmission Profile" form. Enter the mailing address used to receive deliveries via the U.S. Postal Service for your business entity. This should be the mailing address for receiving materials pertaining to this Trading Partner agreement. If this address is the same as the above street address, indicate "Same as above". This section provides the ability to identify individuals within your business entity who can be used as contacts for this Trading Partner relationship. Room has been provided for three business contacts and three technical contacts. The BUSINESS CONTACT is the individual most familiar with the transmission and business processes, as well as data quality issues, within your business entity. He/she may be the project manager, business systems analyst, etc. This individual should be able to track down the answers to any issues, which may arise from your Trading Partner that the technical contact cannot address. Name Address City State Postal Code Mailing Address (Including City/ State/Postal Code) Contact Information The TECHNICAL CONTACT is the individual to be contacted if issues regarding the actual transmission process arise. This individual may be a telecommunications specialist, computer operator, and programmer analyst etc. Name Title Phone Enter the name of the Business/Technical contact. Enter the title of the Business/Technical contact or the role that contact performs within a given Trading Partner relationship. Enter the telephone number at which that Business/Technical contact can be reached. Include extension, if applicable Enter the telephone number of the FAX machine to use for the Business/Technical contact Enter the e-mail address at which that Business/Technical contact can be reached. Enter the mailing address at which that Business/Technical contact can be contacted if different than the Trading Partner mailing address American LegalNet, Inc. www.FormsWorkFlow.com Fax E-mail Mailing Address WC170 05/05