MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS ELECTRONIC DATA DISTRIBUTION TRADING PARTNER PROFILE (Receiver’s Specifications) Trading Partner Type: Insurance Company Claims Administrator Employer Self-Insured Employer Self-Insured Group Trust Attorney (List Name and Bar No. Below) Attorney Firm (List Attorney Names and Bar Nos. Below) Name Address (with 9-digit ZIP code) Master Electronic Mail Address (maximum length of 60 digits) Electronic Mail Software Used Electronic Mail Size Limitation Business Contact: Technical Contact: Name Name Title Title Phone (Include Area Code) Phone (Include Area Code) Fax (Include Area Code) Fax (Include Area Code) Electronic Mail (If different from above) Electronic Mail (If different from above) Correspondence Types: Notice of Conference Text File PDF File Opt out of daily e-mail Notice of Pre-Hearing Notice of Mediation Notice to Show Cause Notice of Cancellation Notice of Hearing Request for Information Letters (X indicates type of correspondence to receive) Attorney and Attorney Firm List: (Attorneys to Receive Notices at Master Electronic Mail Address) Attorney Name Missouri Bar No. Attorney Firm Name E-mail completed Docket Notices Form and Request for Information Letters Form to: Correspondence@labor.mo.gov WC-133 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com Missouri Division of Workers’ Compensation Electronic Data Distribution Terms and Conditions By submitting the Electronic Data Distribution – Trading Partner Profile (Receiver’s Specifications) [hereafter EDD request], the Division and the Trading Partner agree to the following conditions: Electronic transmission of Notice Types or other correspondence as indicated on the Trading Partner Agreement will be sent to the Trading Partner based upon the format selected by the Trading Partner. The Division retains the right to accept or reject the EDD request if the recipient’s mail services are incompatible with the Division’s system. Approval of the EDD request by the Division shall be acknowledged to the Business and Technical Contacts indicated on the EDD request. Upon approval, the Trading Partner and the Division shall begin the test phase of the project. During the test phase, the Trading Partner shall receive correspondence via electronic transmission and paper for five business days. The Division cannot provide notices by electronic transmission if the notice is required to be sent by Certified Mail; if there are nine or more parties to the workers’ compensation case; or if the notice is requested by any of the Division’s adjudication offices to insert additional language into the notice prior to mailing it to the parties of record. The information contained in the documents is based upon information submitted to the Division by the Trading Partner and other parties to the underlying workers’ compensation case. The Division retains the documents sent via electronic transmission as part of the records kept and stored by the Division consistent with the applicable statutory provisions and regulations. All requests for access to the documents will be evaluated and released by the Division consistent with applicable laws, regulation 8 CSR 50-2.020(4) and Department of Labor and Industrial Relations (Department) and Division procedures that apply to electronic security and integrity of the information system. WC-133-2 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com Missouri Division of Workers’ Compensation Electronic Data Distribution Instructions A Trading Partner must complete the Electronic Data Distribution (EDD) Trading Partner Profile and return it to the Division. Docket Notices and Request for Information Letters E-mail to: Correspondence@labor.mo.gov Or mail to: Division of Workers’ Compensation Attention: Correspondence P.O. Box 58 Jefferson City, MO 65102-0058 The following explains each of the items on the form: Trading Partner Type: Check the appropriate trading partner type that applies to your organization. Name: Enter the name of your organization that is used when reporting Workers’ Compensation injuries and for all correspondence with the Division. Address: Enter the address where your organization wants to receive mail. Include street address, city, state, and 9-digit ZIP code. *See address special instructions on page 5. Master Electronic Mail Address: Enter the electronic mail address where the correspondence will be sent. All electronic mail will be sent to one address per Trading Partner unless multiple addresses are requested. This address cannot exceed 60 characters in length and must be a shared electronic mail account with multiple people at the Trading Partner site authorized for access. *See address special instructions on page 5. Electronic Mail Software Used: Enter the type of electronic mail software that will be used to receive EDD correspondence from the Division. You may want to check with the electronic mail system administrator at your site to confirm this information. Electronic Mail Size Limitation: Please note if there is a size limitation on incoming electronic mail at your site. The Trading Partner will want to confirm this information with its electronic mail system administrator. The correspondence files that will be sent to the Trading Partner can be quite large, and some systems limit the size of incoming electronic mail files. Business Contact: List the name, title, phone, fax, and electronic mail address of the Trading Partner business contact. This person will be responsible for business coordination of the EDD project with the Division. WC-133-3 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com Technical Contact: List the name, title, phone, fax, and electronic mail address of the Trading Partner technical contact. This person will be responsible for technical coordination of the EDD project with the Division. Correspondence Types: For each notice type listed, please select the format you wish to receive. Further explanation of these options follows. The following correspondence types are available through EDD: Notice of Conference Notice of Pre-Hearing Notice of Mediation Notice to Show Cause (Dismissal setting) Notice of Cancellation Notice of Hearing Request for Information Letters There currently are two formats available for receiving correspondence electronically. Trading Partners can receive a text file that holds a record for each letter with all information from the letter. It allows Trading Partners the ability to take the data from the file and update the information into their business systems. Large Trading Partners that receive a high volume of correspondence daily may be interested in this option. For those interested in this option, please contact Lyn Williams at 573-526-4955 or send an e-mail to Correspondence@labor.mo.gov to request a copy of the EDD file specifications. The second format is a PDF file that has a copy of the actual letters. When the PDF file is printed locally, the letters look like those printed and mailed by the Division. The Trading Partner will want to save the attachment file to a local PC hard drive or server where they may view, print and distribute the letters as required. The PDF format requires Adobe Acrobat Reader on the PC. This software is free and can be downloaded from the Division Web site under the Forms and Brochures link. Trading Partners can choose how they want to receive each notice and may elect to receive notices in mixed formats. Only one option may be selected for each notice type. Attorney and Attorney Firm List: For Trading Partner Types, Attorney and Attorney Firm, please list each attorney name and bar number for all attorneys in your organization. Please attach additional pages, if necessary. This step is very important to ensure that correspondence addressed to specific attorneys is delivered under your Trading Partner master electronic mail address. Information Request Letters: At times, the Division will request additional information regarding lost time, benefits paid or terminated, medical cost, or reports. Your Division service representative will be able to send you these Request for Information Letters by e-mail. WC-133-4 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com *Address Special Instructions: If you are a Trading Partner that currently receives mail at multiple locations, there are additional options for how your electronic mail can be set up. (1) You may choose to receive electronic mail for all locations at one electronic mail address. Please attach an additional page listing all other addresses where you receive mail. Each address will use the same electronic mail address. Example: TRADING PARTNER PROFILE NAME - SMITH LAW FIRM ADDRESS – 100 MAIN ST, ST LOUIS, MO 61111 ELECTRONIC MAIL ADDRESS – smith@mail.net ADDITIONAL PAGE NAME – SMITH LAW FIRM ADDRESS – 500 BROADWAY ST, KANSAS CITY, MO 65555 ELECTRONIC MAIL ADDRESS – smith@mail.net (2) You may choose to receive electronic mail for each location at a different electronic mail address. Please attach an additional page listing all other addresses where you receive mail, along with the electronic mail address you want to use for each address. Example: TRADING PARTNER PROFILE NAME – SMITH LAW FIRM ADDRESS – 100 MAIN ST, ST LOUIS, MO 61111 ELECTRONIC MAIL ADDRESS – smith.stlouis@mail.net ADDITIONAL PAGE NAME – SMITH LAW FIRM ADDRESS – 500 BROADWAY ST, KANSAS CITY, MO 65555 ELECTRONIC MAIL ADDRESS – smith.kansascity@mail.net WC-133-5 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com