EDI Trading Partner Insurer-Claim Administrator ID List {EDI-2}

FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION EDI TRADING PARTNER INSURER/CLAIM ADMINISTRATOR ID LIST IMPORTANT: Complete all fields designated with an asterisk ( * ). Form will be returned if any required fields are missing. TO: Receiver: Florida Department of Financial Services, Division of Workers' Compensation, EDI Team E-mail: poc.edi@fldfs.com or claims.edi@fldfs.com FROM: Trading Partner*:_______________________________________________________________ Sender Legal Name, if different* (no abbreviations): Sender FEIN*: Date Prepared: ___________________ NOTE: The Sender FEIN and Postal Code should be the same as those that your company will use as the SENDER ID in the Header Record for POC and Claims EDI transmissions, and should match information submitted on your "EDI Trading Partner Profile" (DFS-F5-DWC-EDI-1). In the first column of the table below, provide the full Legal Name for all Insurers/Claim Administrators for which EDI filings will be sent, including self-insurers and any Service Company/Third Party Administrator. Include the Postal Code that corresponds with all of the individual active claims office locations listed on the EDI Trading Partner Profile, DFS-F54-DWV-EDI-1. In the second column, provide each Insurer/Claim Administrator FEIN. In the third column, provide the Division-assigned Carrier Code # and, if applicable, the Service Co/TPA Code # for each Insurer/Claim Administrator. This list will be used to reconcile profile identification records, where the Insurer/Claim Administrator FEIN and Postal Code are the primary keys. If after filing this form with the Division, any entries are added or removed from the listing, the trading partner shall submit a revised EDI Trading Partner Insurer/Claim Administrator ID List in accordance with Rule 69L-56, F.A.C. # Insurer/Claim Administrator Legal Name* and Postal Code(s)* for all Active Claims Offices* Insurer/Claim Administrator FEIN* Carrier Code #* Service Co/TPA Code # (if applicable)* Postal Code* (9 digits): ­ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 16 18 19 20 Use additional page(s) to report more than 20 insurers/claim administrators. DFS-F5-DWC-EDI-2 (01/01/2005) American LegalNet, Inc. www.USCourtForms.com