Fillable Third Party Administrator Location List (Colorado DORA)

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Third Party Administrator Location List (Colorado DORA)

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The Third Party Administrator Location List (Colorado DORA) form is 3 pages long and contains:

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  • 61 other fields

Country of origin: US
File type: PDF

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

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Instructions for Completing the
Third Party Administrator Location List
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This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not
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When you open the form, click in the “Trading Partner Name” 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
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click on the red “Clear Entire Form” button. To change the information
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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
THIRD PARTY ADMINISTRATOR LOCATION LIST
WC171 7/02
Trading Partner Name Date
Enter the FEIN and nine-digit Postal Code that will be used by your company as the SENDER ID in the Header
Record of all EDI transactions. This should match information submitted on your Master Trading Partner Profile.
Master FEIN Postal Code
Address
City, State
Please provide the FEIN, Colorado Division of Workers’ Compensation TPA Code, address, and nine-digit postal
code for each location of the Third Party Administrator that will be transmitting data. We will notify you of any
discrepancy between the identifying information, including the mailing address and the present records of the
Division of Workers’ Compensation. It is understood that this list will have entries added or removed from time to
time.
FEIN
TPA
Code
TPA Name
Address Postal Code
The FEIN and the postal code must match the DN 8 and DN 14, respectively, submitted in your transmissions.
Attach additional sheets as needed.
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Third Party Administrator Location List (Colorado DORA)

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Completed 27 January 2021

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