NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION EDI TRADING PARTNER PROFILE ATTN: STATISTICS PO BOX 27198 ALBUQUERQUE, NM 87125-7198 PLEASE PRINT IN BLACK INK OR TYPE Reporting Purpose Code PARTNER TYPE: TPA □ □ Employer □ Jurisdiction Carrier □ Other Service Bureau □ □ Sender Administrator □ TRADING PARTNER: Name: FEIN: Mail/Address: City: State: Postal Code: Contact Person: Phone: Fax #: □ A49 (Sub. Report) □ Medical □ FREQUENCY OF REPORTING: Weekly □ Daily □ Bi-weekly □ FILE TRANSMISSION: 148 (FROI) □ Other □ Monthly □ Quarterly □ POC FILE TYPE: ANSI □ Annually □ Semi-Annually □ Flat File DAY OF WEEK: □ Sat. □ Sun. □ Mon. □ Tue. □ Wed. □ Thur. □ Fri. □ NETWORK: Production □ Start Date Test □ Start Date_______________ MAIL BOX ACCT. ID: USER ID: MESSAGE CLASS: ORGANIZATIONS REPORTING UNDER SENDER ADMINISTRATOR: Insurer Name Agreement Person FEIN Title Type Signature Postal Code Date FORM WCA E7.1 (7/00) American LegalNet, Inc. www.FormsWorkflow.com