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  • Department of Labor: EDIPacketTPPROF-Partner

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    USA_DepartmentOfLabor
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    SENDER'S TRADING PARTNER PROFILE TYPE: __ Jurisdiction __ Service Bureau __ Employer __ Claims Administrator __ Other (specify): MASTER FEIN: Phy Address: Postal Code: Postal Code: CONTACT INFORMATION: Business Contact: Technical Contacts:

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    SENDER'S TRADING PARTNER PROFILE TYPE: __ Jurisdiction __ Service Bureau __ Employer __ Claims Administrator __ Other (specify): MASTER FEIN: Phy Address: Postal Code: Postal Code: CONTACT INFORMATION: Business Contact: Technical Contacts:

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    7 views2 pages

    Department of Labor: EDIPacketTPPROF-Partner

    Uploaded by

    USA_DepartmentOfLabor
    SENDER'S TRADING PARTNER PROFILE TYPE: __ Jurisdiction __ Service Bureau __ Employer __ Claims Administrator __ Other (specify): MASTER FEIN: Phy Address: Postal Code: Postal Code: CONTACT INFORMATION: Business Contact: Technical Contacts:

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    SENDER’S 

    TRADING PARTNER PROFILE

    TRADING PARTNER TYPE:

    __ Jurisdiction __ Claims Administrator
    __ Service Bureau __ Other (specify):          
                     
       
    __ Employer

    MASTER TRADING PARTNER INFORMATION:

    Name:                               
                     
                     
                     
                     
                     
       
    Master FEIN:  
                                 
                     
                     
                     
                     
                     
       
    Phy Address:  
                                 
                     
                     
                     
                     
                     
       
     
                                 
                     
                     
                     
                     
                     
       
    City:                               
                     
                     
                     
                     
                     
       
    State:  
                                 
        Postal Code:                
                     
                              
       

    Mail Address:                               
                     
                     
                     
                     
                     
       
     
                                 
                     
                     
                     
                     
                     
       
    City:                               
                     
                     
                     
                     
                     
       
    State:  
                                 
        Postal Code:  
                  
                   
       

    CONTACT INFORMATION:

    Business Contact: Technical Contacts:

    Name:                                
                     
                     
        Name:                 
                     
                     
                     
        
    Title:   
                                 
                     
                     
        Title:                
                     
                     
                     
       
    Phone:  
                                 
                     
                     
        Phone:                
                     
                     
                     
       
    FAX:     
                                 
                     
                     
        FAX:                  
                     
                     
                     
         
    E­Mail:  
                                 
                     
                     
        E­mail:                
                     
                     
                     
       

    Name:                 
                     
                     
                     
        Name:                 
                     
                     
                     
        
    Title:               
                     
                     
                     
                  Title:               
                     
                     
                     
        
    Phone:               
                     
                     
                     
        Phone:                
                     
                     
                     
       
    FAX:                  
                     
                     
                     
        FAX:                  
                     
                     
                     
       
    E­Mail:               
                     
                     
                     
        E­Mail:                
                     
                     
                     
       

    Name:                 
                     
                     
                     
        Name:                 
                     
                     
                     
        
    Title:               
                     
                     
                     
                  Title:               
                     
                     
                     
        
    Last Updated
    06/03/03
    Phone:                               
                     
                     
        Phone:                
                     
                     
                     
       
    FAX:                  
                     
                     
                     
        FAX:                  
                     
                     
                     
       
    E­Mail:               
                     
                     
                     
        E­Mail:                
                     
                     
                     
       

    Name:                 
                     
                     
                     
        Name:                 
                     
                     
                     
        
    Title:               
                     
                     
                     
                  Title:               
                     
                     
                     
        
    Phone:               
                     
                     
                     
        Phone:                
                     
                     
                     
       
    FAX:                  
                     
                     
                     
        FAX:                  
                     
                     
                     
       
    E­Mail:               
                     
                     
                     
        E­Mail:                
                     
                     
                     
       

    Last Updated
    06/03/03

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