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OAR 436-160-0310       Appendix A

Data element

INSURED RECORD

Transaction Set ID

DN001

M

M

M

M

M

Record Sequence Number

DN107

M

M

M

M

M

Transaction Set Purpose Code

DN300

M

M

M

M

M

Jurisdiction Designee Received Date

DN302

M

M

M

M

M

Transaction Set Type Code

DN002

M

M

M

M

M

Transaction Reason Code

DN303

M

M

M

M

M

Transaction Set Type Effective Date

DN304

M

M

M

M

M

Insurer FEIN

DN006

M

M

M

M

M

Insurer Name

DN007

M

O

O

O

O

Issuing Office Name

DN305

O

O

O

O

O

Issuing Office Address Line 1

DN306

O

O

O

O

O

Issuing Office Address Line 2

DN307

O

O

O

O

O

Issuing Office City

DN308

O

O

O

O

O

Issuing Office State

DN309

O

O

O

O

O

Issuing Office Postal Code

DN310

O

O

O

O

O

Issuing Agency Name

DN311

O

O

O

O

O

Issuing Agency City

DN312

O

O

O

O

O

Issuing Agency State

DN313

O

O

O

O

O

Insured FEIN

DN314

M

M

M

M

M

Insured Name

DN017

M

M

M

M

M

Insured Address Line 1

DN315

M

O

O

O

O

Insured Address Line 2

DN316

O

O

O

O

O

Insured City

DN317

M

O

O

O

O

Insured State

DN318

M

O

O

O

O

Insured Postal Code

DN319

M

O

O

O

O

Insured Telephone Number

DN320

O

O

O

O

O

Business Market

DN321

O

O

O

O

O

Wrap-Up Indicator

DN322

C

O

O

O

O

Insured Legal Status

DN323

M

O

O

O

O

Employee Leasing Policy Identification

DN333

M

O

O

O

O

Policy Number

DN028

M

M

M

M

M

Policy Effective Date

DN029

M

O

O

O

M

Policy Expiration Date

DN030

O

O

O

O

O

Prior Policy Number

DN324

C

O

O

O

O

Assignment Date

DN325

O

O

O

O

O

Jurisdiction

DN004

M

M

M

M

M

Governing Class

DN326

M

O

O

O

O

Total Payroll

DN327

O

O

O

O

O

Number of Employers

DN328

M

M

M

M

M

EMPLOYER RECORD

Transaction Set ID

DN001

M

M

M

N/A

N/A

Record Sequence Number

DN107

M

M

M

Employer FEIN

DN016

M

M

M

Employer UI Code

DN329

O

O

O

Employer Name

DN018

M

M

O

Employer Address Line 1

DN019

M

O

O

Employer Address Line 2

DN020

O

O

O

Employer City

DN021

M

O

O

Employer State

DN022

M

O

O

Employer Postal Code

DN023

M

O

O

Industry Code

DN025

O

O

O

Number of Employees

DN330

O

O

O

Employer Notification Date

DN331

O

O

O

Page 11

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