"Notice Entry Access Agreement" - Montana

Notice Entry Access Agreement is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on December 29, 2021;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
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Notice Entry Access Agreement
The purpose of this agreement is to provide access for a claim administrator or insurer and/or
an insurer’s designated agent, to the Notice Entry system for existing claims held in the
Employment Relation Division’s (“Division”) workers’ compensation database. Access will be
allowed when a claim administrator and/or insurer or claim administrator is at risk or
responsible for administering a claim. The parties listed above are hereinafter referred to as
“Entity”.
In consideration of obtaining direct access to certain claim information through the Division’s
Notice Entry system, the Entity’s signatory to this agreement agrees to the
following:
1. The information entered must be an accurate reflection of the notice that was sent to the
claimant. The person logged into the system and entering and/or editing information, is
certifying that the information is true and correct at the time of entry or edit.
2. The information obtained from the Division’s workers’ compensation database must remain
confidential and may not be disclosed to any third party except to the extent necessary for
reviewing and editing previously reported information. Users of information
obtained from the workers’ compensation database are liable for damages arising from
misuse or unlawful dissemination of claim information.
3. Claim history information is limited to: claimant’s name; date of birth; claim number; date
of injury; agency claim number; claim administrator; previously reported notice types and
description of the purpose of the notice reported by that claim administrator as shown in the
Montana workers’ compensation database system.
4. Upon approval and execution of this agreement, the Division will assign a unique login
identification and password to the individual(s) identified by the Entity signing this
agreement. The login identification and password must be stored in a secure location
accessible by authorized persons only. Login IDs and passwords must not be shared
with co-workers or future employees that may replace the designated user. The
Division must be promptly notified if an individual no longer needs access to the Notice Entry
System.
5. Due to the very nature of technology, the Division implies no guarantee that this
system will be accessible 100 percent of the time.
6. The Division’s workers’ compensation database contains information on Montana
workers’ compensation claims reported to the Division with an injury date later than
July 1, 1981. This information is shown as it was reported to the Division. Due to
reporting time requirements and late or non-reporting, not all claims may be included
in the database. Claim information is updated nightly Monday through Friday.
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Notice Entry Access – DAR - 12/29/2021
Notice Entry Access Agreement
The purpose of this agreement is to provide access for a claim administrator or insurer and/or
an insurer’s designated agent, to the Notice Entry system for existing claims held in the
Employment Relation Division’s (“Division”) workers’ compensation database. Access will be
allowed when a claim administrator and/or insurer or claim administrator is at risk or
responsible for administering a claim. The parties listed above are hereinafter referred to as
“Entity”.
In consideration of obtaining direct access to certain claim information through the Division’s
Notice Entry system, the Entity’s signatory to this agreement agrees to the
following:
1. The information entered must be an accurate reflection of the notice that was sent to the
claimant. The person logged into the system and entering and/or editing information, is
certifying that the information is true and correct at the time of entry or edit.
2. The information obtained from the Division’s workers’ compensation database must remain
confidential and may not be disclosed to any third party except to the extent necessary for
reviewing and editing previously reported information. Users of information
obtained from the workers’ compensation database are liable for damages arising from
misuse or unlawful dissemination of claim information.
3. Claim history information is limited to: claimant’s name; date of birth; claim number; date
of injury; agency claim number; claim administrator; previously reported notice types and
description of the purpose of the notice reported by that claim administrator as shown in the
Montana workers’ compensation database system.
4. Upon approval and execution of this agreement, the Division will assign a unique login
identification and password to the individual(s) identified by the Entity signing this
agreement. The login identification and password must be stored in a secure location
accessible by authorized persons only. Login IDs and passwords must not be shared
with co-workers or future employees that may replace the designated user. The
Division must be promptly notified if an individual no longer needs access to the Notice Entry
System.
5. Due to the very nature of technology, the Division implies no guarantee that this
system will be accessible 100 percent of the time.
6. The Division’s workers’ compensation database contains information on Montana
workers’ compensation claims reported to the Division with an injury date later than
July 1, 1981. This information is shown as it was reported to the Division. Due to
reporting time requirements and late or non-reporting, not all claims may be included
in the database. Claim information is updated nightly Monday through Friday.
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Notice Entry Access – DAR - 12/29/2021
7. The designated representative is the individual responsible for executing the
Notice Entry agreement, adherence to the terms of this agreement and to authorize and
maintain the approved users.
Designated Representative Information
System access request name:
Company Name:
Phone Number:
Email Address:
Mailing Address:
City:
State:
Zip:
8. The designated representative must complete a Notice Entry User Profile form for each
Notice Entry user.
9. This agreement becomes effective upon receipt by the Division of the signed
agreement and verification of access requirements. To modify or terminate this
agreement, written notification is required within 14 days of the event.
The parties below have executed this Agreement and agree to all conditions stated therein:
__________________________________________________________ _____________________
Designated Representative Signature
Date
__________________________________________________________ _____________________
Division Representative Signature
Date
Please return the form upon completion to:
Doug Roope
Doug.Roope@mt.gov
Fax (406) 444-4140
Tel. (406) 444-1600
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Notice Entry Access – DAR - 12/29/2021
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