COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKER S COMPENSATION SENDERS TRANSMISSION PROFILE Return This Page To: Date Receiver Name Colorado Division of Workers Compensation Receiver Identifier FEIN 840644739 Postal Code 80202-2117 Profile ID N/A Description Release 1 Transmission Requirements SENDER MASTER TRADING PARTNER SELECTIONS/INFORMATION . Name FEIN Postal Code Type Jurisdiction Claims Admin Employer Service Bureau Other (describe) Transaction Information Acknowledgement Information Transaction Format Release/Version Projected Number per Mode Level IAIABC/ANSI Transaction 148/148 A49/148 AKI/824 Transmission Frequencies (select only one fromReceivers options) Daily Weekly Select Sun Mon Tue Wed Thu Fri Sat All Monthly Select Day (1-31) Quarterly Select Month(s) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec All Select Day (1-31) Annually Select Month(s) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec All Select Day (1-31) Other Transmission Cut off Time Selected Media Electronic Mailbox NA Direct Connect Electronic Mailbox Information Network Test Prod Mailbox Acct ID User ID Message Class WC169 7/02 >>>> 2 INSTRUCTIONS / DEFINITIONS This form is used to communicate all alwabllo e options the Sender of workers compensation data will provide to the Colorado Division of Workers Compensation (DOWC). DOWC is responsible for providing the information on the Receiver form, indicating all their requirements and where applicable, the supported options from which the Sender can select. The Sender will then complete the Senders Response formro pviding data in the allotted spaces and indicating selections where the Receiver provides choices. This information is then returned to ther.e Re ceiv Although one profile will satisfy most needs, it should be noted that if transmission parameters vary by transaction set IDs, ou could specifyy those differences by providing more than one profile. Receiver Name, Receiver FEIN, Receiver Postal Code, Pofile ID and Drescription will be pre-filled by DOWC. Master Trading Partner Sender Selections/Information Name Enter the name of the business entity that will be extracting and transmitting detailed workers compensation information to DOWC. This should be thne ame that appears on the Trading Partner Profile form. FEIN Enter the Federal Employer Identification Number (FEIN) of the trading partner that will transmit workers compensation data. This must match the FEIN supplied on the entitys Trading rtner Profile Paform. Postal Code Enter the nine (9) digit postal code associated with the Sender Trading Partners physical address, which together with the Sender FEIN, will be used as the identer of this trading pifiartner. This must match the postal code supplied on the entitys Trading Partner Profile form. Type Check the appropriate category reflecting the Sers business type. nde If other, please describe. Transaction Information Format Indicate the format of each transaction set for which an agreement is being made Flat File or ANSI. The format and Release/Version number that the Sender wants to receive electronic detailed acknowledgments is specifiedon th e line indicated by AK1/824. Release/Version If flat file was selected, the IAIABC Release Numb is speciferied in this space. If ANSI format was selected, the ANSI Version Number is specified in this space. Projected Number per Transaction Specify the projected average number of detail rrds for a giveneco Transaction Set ID that will be sent to the Receiver Trading Partner. Th is will be used for planning purposes. Acknowledgment Information Mode Select the preferred mode (electronic/paper/none) of acknowledments for that transaction set g from the options provided by the DOWC on the Receivers Transmission Profile. Level Select the preferred level (all/errors/rejected) of acknowledgments for the transaction set from the options provided by the DOWC one th Receivers Transmission Profile. Transmission Frequency Frequency All frequencies the DOWC (Receiver Trading Partner) will accept transmissions for the transaction set identified within this profile are specified here. DOWC supports daily transmissions only for FROI. Transmission Cut-Off Time Enter the anticipated transmission time of the Sender. All transmissions must be received by 6:00 p.m. Mountain Time, in order to be included in that days business. Selected Media Place an X in front of the option selected to transmit information. If Internet Connect is selected, DOWC must provide an technicaly specifications that the Sender will need for successful data exchange. If Valued Added Network(VAN) is selected, supply the electronic mailbox network information in the fields that are provided for the specific VAN. Electronic Mailbox Information Network: Specify the VAN used to transmit data to DOWC. Separate mailbox information is provided for production versus test transmissions. Mailbox Acct ID: The name of the mailbox on this VAN where acknowledgments can be routed from DOWC back to the Sender. User ID: This is the Sender identifier to the VAN. Message Class: If this VAN allows for slots in their mailbox (ssification ofcla messages), this field will contain the message class to use when transmitting information back to the sending entity. WC169 7/02