Trading Partner Insurer List {WC172} | Pdf Fpdf Doc Docx | Colorado

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Trading Partner Insurer List {WC172} | Pdf Fpdf Doc Docx | Colorado

Trading Partner Insurer List {WC172}

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

Alternate TextLast updated: 5/17/2006

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKER S COMPENSATION TRADING PARTNER INSURER LIST Trading Partner Name Date Enter the FEIN and nine-digit Postal Code that will be used by your company as the SENDER ID in the Header Record of all EDI transactions. This should match infrmation submitted on o you Master Trading Partner Profile. Master FEIN Postal Code Address City, State Please provide the FEIN, Colorado Division of Workers Compensation Block Number and legal name for each carriers and self-insureds claims you will be transmitting. We will notify you of any discrepancy between the identifying information below and the present records of the Division of Workers Compensation. It is understood that this list may have entries added or removed from time to time. Block FEIN Number Name of CO Authorized Carrier or CO Approved Self Insured The FEINs must match the various values of DN 6 submitted in your transmissions. Attach additional sheets as needed. WC172 7/02

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