Fillable Senders Transmission Profile (Colorado DORA)

Fill Online, Printable, Fillable, Blank Senders Transmission Profile (Colorado DORA) Form

Use Fill to complete blank online COLORADO DORA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Senders Transmission Profile (Colorado DORA)

On average this form takes 12 minutes to complete

The Senders Transmission Profile (Colorado DORA) form is 4 pages long and contains:

  • 0 signatures
  • 48 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your DORA forms online.

Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

BROWSE COLORADO DORA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
Instructions for Completing the
Sender’s Transmission 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 “Date” box (field) and use the
tab key to navigate to the next field. Do not use the Enter
key; press-
ing 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.
To fill in a check box, click inside the box with your mouse. Some
fields contain a drop down menu; click on the arrow and select one
of the choices
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.
Go to Form
2
“Clear Entire Form” button
Clears all information at once
3
“Check Box”
Click in Box
“Drop Down Menu”
Click on the arrow for choices
WC169 07/02
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
SENDER’S TRANSMISSION PROFILE
Return This Page To:
Date
Receiver Name
Colorado Division of Worker’s Compensation
Receiver Identifier
FEIN 840644739
Postal Code 80202-2117
Profile ID
N/A
Description
Release 1 Transmission Requirements
SENDER MASTER TRADING PARTNER SELECTIONS/INFORMATION
Name
.
FEIN
Postal Code
Type
Jurisdiction
Claims Admin
Employer
Service Bureau
Other (describe)
Transaction Information
Acknowledgement Information
Transaction
IAIABC/ANSI
Format
Release/Version
Projected Number per
Transaction
Mode
Level
148/148
A49/148
AKI/824
Transmission Frequencies (select only one from Receiver’s options)
Daily
Weekly
Select
Sun
Mon
Tue
Wed
Thu
Fri
Sat
All
Monthly
Select Day (1-31)
Quarterly
Select Month(s)
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
All
Select Day (1-31)
Annually
Select Month(s)
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
All
Select Day (1-31)
Other
Transmission Cut off Time
Selected Media
Electronic Mailbox NA Direct Connect
Electronic Mailbox Information
Network
Test Prod
Mailbox Acct ID
User ID
Message Class
Clear Entire Form
Back to Instructions
WC169 07/02
INSTRUCTIONS / DEFINITIONS
This form is used to communicate all allowable options the Sender of workers’ compensation data will provide to the Colorado Division of Workers’
Compensation (DOWC). DOWC is responsible for providing the information on the Receiver form, indicating all their requirements and where
applicable, the supported options from which the Sender can select. The Sender will then complete the Sender’s Response form providing data in the
allotted spaces and indicating selections where the Receiver provides choices. This information is then returned to the Receiver.
Although one profile will satisfy most needs, it should be noted that if transmission parameters vary by transaction set IDs, you could specify those
differences by providing more than one profile.
Receiver Name, Receiver FEIN, Receiver Postal Code, Profile ID and Description will be pre-filled by DOWC.
Master Trading Partner Sender Selections/Information
Name
Enter the name of the business entity that will be extracting and transmitting detailed workers’ compensation information
to DOWC. This should be the name that appears on the “Trading Partner Profile” form.
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 “Trading Partner Profile” form.
Postal Code
Enter the nine (9) digit postal code associated with the Sender Trading Partner’s physical address, which together with the
Sender FEIN, will be used as the identifier of this trading partner. This must match the postal code supplied on the
entity’s “Trading Partner Profile” form.
Type
Check the appropriate category reflecting the Sender’s business type. If other, please describe.
Transaction Information
Format
Indicate the format of each transaction set for which an agreement is being made – Flat File or
ANSI. The format and Release/Version number that the Sender wants to receive electronic
detailed acknowledgments is specified on the line indicated by “AK1/824”.
Release/Version
If flat file was selected, the IAIABC Release Number is specified in this space. If ANSI format
was selected, the ANSI Version Number is specified in this space.
Projected Number per Transaction
Specify the projected average number of detail records for a given Transaction Set ID that will be
sent to the Receiver Trading Partner. This will be used for planning purposes.
Acknowledgment Information
Mode
Select the preferred mode (electronic/paper/none) of acknowledgments for that transaction set
from the options provided by the DOWC on the Receiver’s Transmission Profile.
Level
Select the preferred level (all/errors/rejected) of acknowledgments for the transaction set from the
options provided by the DOWC on the Receiver’s Transmission Profile.
Transmission Frequency
Frequency
All frequencies the DOWC (Receiver Trading Partner) will accept transmissions for the
transaction set identified within this profile are specified here. DOWC supports daily
transmissions only for FROI.
Transmission Cut-Off Time
Enter the anticipated transmission time of the Sender. All transmissions must be received by 6:00
p.m. Mountain Time, in order to be included in that day’s business.
Selected Media
Place an “X” in front of the option selected to transmit information. If “Internet Connect” is selected, DOWC must provide any technical
specifications that the Sender will need for successful data exchange. If “Valued Added Network”(VAN) is selected, supply the electronic mailbox
network information in the fields that are provided for the specific VAN.
Electronic Mailbox Information
Network:
Specify the VAN used to transmit data to DOWC. Separate mailbox information is provided for
production versus test transmissions.
Mailbox Acct ID:
The name of the mailbox on this VAN where acknowledgments can be routed from DOWC back
to the Sender.
User ID:
This is the Sender identifier to the VAN.
Message Class:
If this VAN allows for “slots” in their mailbox (classification of messages), this field will contain
the message class to use when transmitting information back to the sending entity.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Senders Transmission Profile (Colorado DORA)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document