Fillable Senders Trading Partner Profile (Colorado DORA)

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Senders Trading Partner Profile (Colorado DORA)

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The Senders Trading Partner Profile (Colorado DORA) form is 3 pages long and contains:

  • 0 signatures
  • 6 check-boxes
  • 56 other fields

Country of origin: US
File type: PDF

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1
Instructions for Completing the
Sender’s Trading Partner Profile
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not
be able
to save the form onto your computer’s hard drive.
When you open the form, click in the appropriate check box (field)
and use the tab key to navigate to the next field. Do not use the Enter
key; pressing the Enter key will only page down. Each field has been
limited. This means that you cannot continue to type information into
a field if it doesn’t fit into the space provided.
Use numbers only
to fill in the fields for phone and fax numbers. Do not
use dashes or parentheses; when you tab out of the field, it will fill in
automatically. To fill in a check box, click inside the box with your
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To clear or delete all the information you have typed onto the form,
click on the red “Clear Entire Form” button. To change the information
in one field, use the backspace or delete key.
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2
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“Check Box”
Click in Box
WC170 7/02
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
SENDER’S TRADING PARTNER PROFILE
Date
Trading Partner Type
Jurisdiction Service Bureau
Carrier Third Party Administrator
Self Insured Employer Other (please specify)
Trading Partner
FEIN
Name
Address
City State Postal Code
Mailing Address (if different)
City
State
Postal Code
Contact Information
Business Contact Technical Contact
Name
Name
Title
Title
Phone
Phone
Fax
Fax
E-mail
E-mail
Mailing
Mailing
Address
Address
Business Contact Technical Contact
Name
Name
Title
Title
Phone
Phone
Fax
Fax
E-mail
E-mail
Mailing
Mailing
Address
Address
Business Contact Technical Contact
Name
Name
Title
Title
Phone
Phone
Fax
Fax
E-mail
E-mail
Mailing
Mailing
Address
Address
Clear Entire Form
Back to Instructions
WC170 7/02
INSTRUCTIONS / DEFINITIONS
This form is used to communicate the Sender’s contact information. Colorado Department of Workers’ Compensation
(DOWC) is responsible for providing contact information on the Receiver form. The completed forms are exchanged between
the Receiver and Sender.
Date
Enter the date the Trading Partner Profile is completed by the Sender.
Trading Partner Type
Check the appropriate category reflecting the Sender’s business type. If other, please specify.
Trading Partner
This section provides identifying information about the Master Trading Partner.
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 entity’s “Transmission
Profile” form. This, along with the 9-digit postal code (Zip+4) in the Trading Partner address field,
will be used to identify a unique Sender.
Name
Enter the name of your business entity corresponding with the FEIN that will be transmitting
detailed workers’ compensation information to DOWC. This must match the Name supplied on
the entity’s “Transmission Profile” form.
Address
Enter the street address of the physical location of your business entity. It will represent where
materials may be received regarding this Sender if using a delivery service other then the U.S.
Postal Service.
City
Enter the city portion of the street address of your business entity.
State
Enter the two (2) character standard state abbreviation of the state portion of the street address of
your business entity.
Postal Code
Enter the nine (9) digit postal code of the street address of your business entity. This field, along
with Trading Partner FEIN will be used to uniquely identify a Trading Partner. This must match
the postal code supplied on the entity’s “Transmission Profile” form.
Mailing Address
(Including City/
State/Postal Code)
Enter the mailing address used to receive deliveries via the U.S. Postal Service for your business
entity. This should be the mailing address for receiving materials pertaining to this Trading Partner
agreement. If this address is the same as the above street address, indicate “Same as above”.
Contact Information
This section provides the ability to identify individuals within your business entity who can be
used as contacts for this Trading Partner relationship. Room has been provided for three business
contacts and three technical contacts.
The BUSINESS CONTACT is the individual most familiar with the transmission and business
processes, as well as data quality issues, within your business entity. He/she may be the project
manager, business systems analyst, etc. This individual should be able to track down the answers
to any issues, which may arise from your Trading Partner that the technical contact cannot address.
The TECHNICAL CONTACT is the individual to be contacted if issues regarding the actual
transmission process arise. This individual may be a telecommunications specialist, computer
operator, and programmer analyst etc.
Name
Enter the name of the Business/Technical contact.
Title
Enter the title of the Business/Technical contact or the role that contact performs within a given
Trading Partner relationship.
Phone
Enter the telephone number at which that Business/Technical contact can be reached. Include
extension, if applicable
Fax
Enter the telephone number of the FAX machine to use for the Business/Technical contact
E-mail
Enter the e-mail address at which that Business/Technical contact can be reached.
Mailing Address
Enter the mailing address at which that Business/Technical contact can be contacted if different
than the Trading Partner mailing address
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Senders Trading Partner Profile (Colorado DORA)

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Completed 27 January 2021

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