Electronic Data Interchange Trading Partner Agreement Third Party Administrator Attachment | Pdf Fpdf Doc Docx | Montana

 Montana   Workers Compensation 
Electronic Data Interchange Trading Partner Agreement Third Party Administrator Attachment | Pdf Fpdf Doc Docx | Montana

Last updated: 11/2/2023

Electronic Data Interchange Trading Partner Agreement Third Party Administrator Attachment

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Description

ELECTRONIC DATA INTERCHANGE (EDI) TRADING PARTNER AGREEMENT Trading Partner Profile Attachment Trading Partners often send reports to DLI/ERD for several insurers or employers. Please complete the following for each insurer or employer Federal Employer Identification Number (FEIN). Insurance company or employer name: ______________________________________________ FEIN: ____________________________ Insurance company or employer name: ______________________________________________ FEIN: ____________________________ Insurance company or employer name: ______________________________________________ FEIN: ____________________________ Insurance company or employer name: ______________________________________________ FEIN: ____________________________ Insurance company or employer name: ______________________________________________ FEIN: ____________________________ Trading Partner Profile Attachment/dje5-27-14 DLI-ERD-WCC044 American LegalNet, Inc. www.FormsWorkFlow.com

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