EDI Trading Partner Profile {EDI-1}

FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION EDI TRADING PARTNER PROFILE IMPORTANT: Complete all fields designated with an asterisk ( * ). Form will be returned if any required fields are missing. Submit to: Date ______________ Receiver Name: Florida Department of Financial Services, Division of Workers' Compensation E-mail: poc.edi@myfloridacfo.com or claims.edi@myfloridacfo.com TRADING PARTNER TYPE* (check all that apply): Insurer Self-Insurer Service Co/Third Party Administrator Large Deductible Employer Handling Its Own Claims Vendor (POC Only) MASTER TRADING PARTNER INFORMATION: Sender Legal Name* (no abbreviations): Sender ID: The Federal Employer Identification Number of your business entity. This, along with your 9-digit Postal Code (Zip+4), will be used to identify a unique trading partner. The Sender FEIN and Postal Code provided below should be the same FEIN and Postal Code that will be sent for the SENDER ID in the Header Record for your POC and Claims EDI transmissions. Sender FEIN*: Physical Address/Office Location: Address Line 1*: Address Line 2: City*: Postal Code* (9 digits): ­ State*: Postal Code*: ­ Mailing Address/Office Location: Address Line 1*: Address Line 2: City*: State*: Postal Code*: ­ Contact Information: Claims EDI Business Contact*: Name: Title: Phone: FAX: E-mail: Business Contact*: Name: Title: Phone: FAX: E-mail: Proof of Coverage (POC) Technical Contact*: Name: Title: Phone: FAX: E-mail: Preparer Information*: Name: Title: Phone: FAX: E-mail: Is the Master Trading Partner Address/Office Location provided above also an active claims office location at which workers' compensation claims will be handled/adjusted? * DFS-F5-DWC-EDI-1(1/01/2008) Rule 69L-56.001, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION EDI TRADING PARTNER PROFILE INDIVIDUAL TRADING PARTNER OFFICE INFORMATION: Will addresses/office locations other than, or in addition to, the Master Trading Partner address/office location be handling/adjusting EDI filings? * If yes, complete the DFS-F5-DWC-EDI-2A and the contact information below for each address/office location that will be handling/adjusting EDI filings to the Division. Include multiple sheets if necessary. Claim Administrator FEIN*: EDI Business Contact: Name: Title: Phone: FAX: E-mail: Postal Code*: EDI Business Contact: Name: Title: Phone: FAX: E-mail: ­ EDI Technical Contact: Name: Title: Phone: FAX: E-mail: Claims Manager: Name: Title: Phone: FAX: E-mail: Claim Administrator FEIN*: EDI Business Contact: Name: Title: Phone: FAX: E-mail: Postal Code*: EDI Business Contact: Name: Title: Phone: FAX: E-mail: ­ EDI Technical Contact: Name: Title: Phone: FAX: E-mail: Claims Manager: Name: Title: Phone: FAX: E-mail: Claim Administrator FEIN*: EDI Business Contact: Name: Title: Phone: FAX: E-mail: Postal Code*: EDI Business Contact: Name: Title: Phone: FAX: E-mail: ­ EDI Technical Contact: Name: Title: Phone: FAX: E-mail: DFS-F5-DWC-EDI-1(1/01/2008) Claims Manager: Name: Title: Phone: FAX: E-mail: Rule 69L-56.001, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com