Electronic Data Distribution Trading Partner Profile {WC-133} | Pdf Fpdf Doc Docx | Missouri

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Electronic Data Distribution Trading Partner Profile {WC-133} | Pdf Fpdf Doc Docx | Missouri

Electronic Data Distribution Trading Partner Profile {WC-133}

This is a Missouri form that can be used for Workers Comp.

Alternate TextLast updated: 10/14/2011

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS ELECTRONIC DATA DISTRIBUTION TRADING PARTNER PROFILE (Receiver's Specifications) Trading Partner Type: Insurance Company Claims Administrator Name Address (with 9-digit ZIP code) Master Electronic Mail Address (maximum length of 60 digits) Electronic Mail Software Used Electronic Mail Size Limitation Employer Self-Insured Employer Self-Insured Group Trust Attorney (List Name and Bar No. Below) Attorney Firm (List Attorney Names and Bar Nos. Below) Business Contact: Name Title Phone (Include Area Code) Fax (Include Area Code) Electronic Mail (If different from above) Technical Contact: Name Title Phone (Include Area Code) Fax (Include Area Code) Electronic Mail (If different from above) Correspondence Types: Notice of Conference Notice of Pre-Hearing Notice of Mediation Notice to Show Cause Notice of Cancellation Notice of Hearing Request for Information Letters Text File PDF File Opt out of daily e-mail (X indicates type of correspondence to receive) Attorney and Attorney Firm List: (Attorneys to Receive Notices at Master Electronic Mail Address) Attorney Name Missouri Bar No. Attorney Firm Name E-mail completed Docket Notices Form and Request for Information Letters Form to: Correspondence@labor.mo.gov WC-133 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com Missouri Division of Workers' Compensation Electronic Data Distribution Terms and Conditions By submitting the Electronic Data Distribution ­ Trading Partner Profile (Receiver's Specifications) [hereafter EDD request], the Division and the Trading Partner agree to the following conditions: Electronic transmission of Notice Types or other correspondence as indicated on the Trading Partner Agreement will be sent to the Trading Partner based upon the format selected by the Trading Partner. The Division retains the right to accept or reject the EDD request if the recipient's mail services are incompatible with the Division's system. Approval of the EDD request by the Division shall be acknowledged to the Business and Technical Contacts indicated on the EDD request. Upon approval, the Trading Partner and the Division shall begin the test phase of the project. During the test phase, the Trading Partner shall receive correspondence via electronic transmission and paper for five business days. The Division cannot provide notices by electronic transmission if the notice is required to be sent by Certified Mail; if there are nine or more parties to the workers' compensation case; or if the notice is requested by any of the Division's adjudication offices to insert additional language into the notice prior to mailing it to the parties of record. The information contained in the documents is based upon information submitted to the Division by the Trading Partner and other parties to the underlying workers' compensation case. The Division retains the documents sent via electronic transmission as part of the records kept and stored by the Division consistent with the applicable statutory provisions and regulations. All requests for access to the documents will be evaluated and released by the Division consistent with applicable laws, regulation 8 CSR 50-2.020(4) and Department of Labor and Industrial Relations (Department) and Division procedures that apply to electronic security and integrity of the information system. WC-133-2 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com Missouri Division of Workers' Compensation Electronic Data Distribution Instructions A Trading Partner must complete the Electronic Data Distribution (EDD) Trading Partner Profile and return it to the Division. Docket Notices and Request for Information Letters E-mail to: Or mail to: Correspondence@labor.mo.gov Division of Workers' Compensation Attention: Correspondence P.O. Box 58 Jefferson City, MO 65102-0058 The following explains each of the items on the form: Trading Partner Type: Check the appropriate trading partner type that applies to your organization. Name: Enter the name of your organization that is used when reporting Workers' Compensation injuries and for all correspondence with the Division. Address: Enter the address where your organization wants to receive mail. Include street address, city, state, and 9-digit ZIP code. *See address special instructions on page 5. Master Electronic Mail Address: Enter the electronic mail address where the correspondence will be sent. All electronic mail will be sent to one address per Trading Partner unless multiple addresses are requested. This address cannot exceed 60 characters in length and must be a shared electronic mail account with multiple people at the Trading Partner site authorized for access. *See address special instructions on page 5. Electronic Mail Software Used: Enter the type of electronic mail software that will be used to receive EDD correspondence from the Division. You may want to check with the electronic mail system administrator at your site to confirm this information. Electronic Mail Size Limitation: Please note if there is a size limitation on incoming electronic mail at your site. The Trading Partner will want to confirm this information with its electronic mail system administrator. The correspondence files that will be sent to the Trading Partner can be quite large, and some systems limit the size of incoming electronic mail files. Business Contact: List the name, title, phone, fax, and electronic mail address of the Trading Partner business contact. This person will be responsible for business coordination of the EDD project with the Division. WC-133-3 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com Technical Contact: List the name, title, phone, fax, and electronic mail address of the Trading Partner technical contact. This person will be responsible for technical coordination of the EDD project with the Division. Correspondence Types: For each notice type listed, please select the format you wish to receive. Further explanation of these options follows. The following correspondence types are available through EDD: Notice of Conference Notice of Pre-Hearing Notice of Mediation Notice to Show Cause (Dismissal setting) Notice of Cancellation Notice of Hearing Request for Information Letters There currently are two formats available for receiving correspondence electronically. Trading Partners can receive a text file that holds a record for each letter with all information from the letter. It allows Trad

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