Workers222 Compensation Division Oregon Workers' Compensation Division Proof of Coverage EDI Transmission Profile Sender type (check all that apply) Insurer Third - party v endor Sender information Le gal name (no abbreviations): FEIN: IP a ddress : Postal code: Physical address: City, state, ZIP+4: Mailing address: City, state, ZIP+4: Contact information Name: Title: Phone: Fax: E mail: Transaction set information Transmission Type IAIABC Format Release POC Flat File 2.1 Frequency Daily Other Describe: Selected Media Proof of Coverage: Secure File Transfer Protocol (SFTP) compatible with Open Secure Shell (SSH), Version 2 Protocol If you have questions about this form, contact the EDI coordinator, 503-947-7742, or email edinews.wcd@state.or.us. Send to: EDI Coordinator, Workers222 Compensation Division, Operations Section, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309 Or fax to 503 - 947 - 7514 4979 Or email to edinews.wcd@state.or.us 440 - 4979 ( 0 4 /1 5 /DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com