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First Report EDI Confirmation Report Format (5/03)

Field Name                                    Length of Field                                     Position of Field                                    Contents

Confirmation Title Line #1
Text                                              25                                                         1-24                             “Confirmation report for “
Filler                                             1                                                            25
Reporter Name                             10                                                          26-35
Date File Received                        8                                                            36-43


Confirmation Title Line #2
Text                                             4                                                             1-4                               “WCBN”
Filler                                            8                                                             5-12
Text                                             4                                                             13-16                           “UIAN”
Filler                                            4                                                             17-20
Text                                             4                                                             21-24                           “NAME”
Filler                                            14                                                           25-38
Text                                             3                                                             39-41                           “SSN”
Filler                                            7                                                             42-48
Text                                             8                                                             49-56                           “Inj Date”
Filler                                            13                                                           57-69
Text                                             9                                                             70-78                           “Ins. File”

Confirmation Data Record
WCBN                                        8                                                             1-8
Filler                                            1                                                              9
UIAN                                          10                                                           10-19
Filler                                            1                                                              20
Name                                          15                                                            21-35
Filler                                            1                                                              36
SSN                                            10                                                            37-47
Filler                                            1                                                              48
Injury Date                                  10                                                             49-58
Filler                                            1                                                              59
Text                                             9                                                              60-68                         “Add” or “Corrected”
Filler                                            1                                                              69
Insurer File Number                     15                                                            70-84