REQUEST FOR INSURER INFORMATION Colorado Division of Workers222 Compensation Coverage EnforcementYou must complete and return this form within 20 days of . Failure to complete this form in a timely manner will delay the claim process and may result in penalties. Please type or print the contact information and sign the form. See Page 3 for instructions. A Block Number will be assigned to the insurer by the Division of Workers222 Compensation once we have forms, including First Report transmittals and correspondence submitted to the Division.If you already have a block number with the Division, please list it here: þ þ .1. þ þ þ þ Name of Carrier þ NCCI Provider Group ID# þ þ þ Carrier FEIN # þ NCCI Provider ID# þ þ þ Street Address/P.O. Box þ Phone # þ þ þ City, State, Zip þ Fax # 2. þ þ þ þ Name of Carrier þ Phone # þ þ þ Street Address/P.O. Box þ Fax # þ City, State, Zip3. þ þ þ þ Name of Claims Contact þ Email Address þ þ þ Street Address/P.O. Box þ Phone # þ þ þ City, State, Zip þ Fax # 4. þ þ þ þ Name of Proof of Coverage Contact þ Email Address þ þ þ Street Address/P.O. Box þ Phone # þ þ þ City, State, Zip þ Fax # 5. þ þ þ þ Name of Premium Surcharge Contact þ Email Address þ þ þ Street Address/P.O. Box þ Phone # þ þ þ City, State, Zip þ Fax # American LegalNet, Inc. www.FormsWorkFlow.com 6. þ EDI Business Contact þ þ þ Name of EDI Business Contact þ Email Address þ þ þ Street Address/P.O. Box þ Phone # þ þ þ City, State, Zip þ Fax # 7. þ EDI Technical Contact þ þ þ Name of EDI Technical Contact þ Email Address þ þ þ Street Address/P.O. Box þ Phone # þ þ þ City, State, Zip þ Fax # 8. þ If there is more than one adjusting company, attach additional pages with full information for each. þ þ þ Name of Adjusting Company þ Email Address þ þ þ Street Address/P.O. Box þ Phone # þ þ þ City, State, Zip þ Fax # 9. þ þ þ þ Name þ Email Address þ þ þ Title þ Phone # þ þ þ Signature (REQUIRED) þ DateReturn this form to:Division of Workers222 CompensationCoverage Enforcement Unit633 17th Street, Suite 400Denver, CO 80202 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS1. þ Complete the name, address, phone and fax numbers of the of the insurer. Enter the Federal insurance carrier.2. þ Complete the name, address, phone and fax numbers of the . This is the address that the Division uses to send correspondence such as rules and administrative notices. If this section is blank, correspondence the carrier, . List the TPA in Section #10.3. þ Complete the name, address, phone and fax numbers, and email address for the person designated as the Claims Contact for Colorado claimsissues, prepare for compliance reviews and have the authority to respond to audits by the Division of Workers222 Compensation. This address will receive workers222 claims for compensation, correspondence regarding admissions, the carrier, . List the TPA in Section #10.4. þ Complete the name, address, phone and fax numbers, and email address for the person designated as the Coverage Contact for Colorado policiesof policy information are sent to this person.5. þ Complete the name, address, phone and fax numbers, and email address for the person designated as the Surcharge Contactthe surcharge report and submitting payment to the Division.6. þ Complete the name, address, phone and fax numbers, and email address for the person designated as the Electronic Business Contact. This should be the person most familiar with the overall extract and transmission process within your business entity. This may be the project manager, business analyst, or claims manager. This person should be able to track down the answers to any business EDI issues that the EDI Technical Contact cannot address.7. þ Complete the name, address, phone and fax numbers, and email address for the person designated as the Electronic . This person will be contacted if issues regarding the actual transmission process arise. This person may be a telecommunications specialist, computer programmer or systems analyst.8. þ If the insurer uses a to adjust Colorado claims, complete the name, address, phone 9. þ Print the name, title, phone number, and email address of the person completing this form. This person must sign the form.Return the completed form to:Division of Workers222 CompensationCoverage Enforcement Unit633 17th Street, Suite 400Denver, CO 80202Any changes to this information must be reported to the Division of Workers222 Compensation in writing. If you have any questions, please contact the Division of Workers222 Compensation at 303.318.8700. American LegalNet, Inc. www.FormsWorkFlow.com