FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS’ COMPENSATION EDI TRANSMISSION PROFILE - SENDER'S SPECIFICATIONS IMPORTANT: Complete all fields designated with an asterisk ( * ). Form will be returned if any required fields are missing. Return this page to: Date Receiver Name: Florida Department of Financial Services, Division of Workers’ Compensation poc.edi@fldfs.com or claims.edi@fldfs.com E-mail: Sender Legal Name* (no abbreviations): Insurer Self-Insurer Sender Type*: Sender ID – FEIN*: Third Party Administrator Vendor (POC Only) Postal Code* (9 digits): Transaction Information TYPE Release/ Version MTC’s* ANSI ANSI Ver POC FROI SROI 2.1 3.0 3.0 N/A N/A N/A N/A N/A N/A N/A Projected # per Transmission* Acknowledgment Information AcknowledgMode Prod ment Record Response AKP EDI Next bus day AKC EDI Next bus day AKC EDI Next bus day Transmission Frequency*(select only one option from the “EDI Transmission Profile - Receiver's Specifications”) Daily Weekly – Specify Day(s): SUN MON TUE WED THU FRI SAT Transmission Cut-off Time (military): 2100 EST Jurisdiction Approved Transmission Method*(select only one option from the “EDI Transmission Profile Receiver's Specifications”) If VAN is used, provide the below required Electronic Mailbox information*. Network (VAN) FTP Electronic Mailbox: Network: ADVANTIS Test Production Mailbox Acct ID: User ID: Message Class: Transmission Payments: Sender will assume all costs associated with sending and receiving transactions Vendor (if applicable)* Vendor Name File Transfer Protocol: Web Site IP Address/URL: See Trading Partner FTP instructions for detailed information User ID: Security Protocol: Secure Socket Layer (SSL) recommended Certificates: Bi-Directional Exchange of digital certificates recommended Auditing: Non-repudiation is recommended, i.e., the system must have an auditable tracking of transfers to/from each trading partner Encryption Level: 112 bit minimum recommended Receiver Requirements See FL Secure Socket Layer (SSL) / File Transfer Protocol (FTP) Instructions Assigned by DWC Required - See FL Secure Socket Layer (SSL) / File Transfer Protocol (FTP) Instructions Required - See FL Secure Socket Layer (SSL) / File Transfer Protocol (FTP) Instructions Required - See FL Secure Socket Layer (SSL) / File Transfer Protocol (FTP) Instructions 128 bit - See FL Secure Socket Layer (SSL) / File Transfer Protocol (FTP) Instructions Draft DFS-F5-DWC-EDI-3 (10/01/2006) American LegalNet, Inc. www.FormsWorkflow.com