Step 1 of 4 25% Payer InformationResponsible Party (company name)*The payer will be invoiced quarterly by NM DOH. Federal EIN*000000000Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Questions? Contact NM OSI: VPA.Data@state.nm.us | (505) 322-2186 Contact* First Last Department*Contact title*Telephone*Email address* Questions? Contact NM OSI: VPA.Data@state.nm.us | (505) 322-2186 Alternative contact name*Department*Title*Phone*Email* Questions? Contact NM OSI: VPA.Data@state.nm.us | (505) 322-2186 Payer Type (select one):* Fully-insured commercial health plan Third-party administrator for a single self-funded health plan Third-party administrator for two or more self-funded health plans Employer with a self-funded health plan Number of lives*Please enter a number from 0 to 99999. In the box above, enter the number of children under the age of 19 enrolled in the health insurance plan on December 31, 2019. Exclude those enrolled in Medicaid or any medical assistance program administered by DOH, and those who are American Indian or Alaska Natives. If no children were enrolled, enter 0. Third-party administrators for two or more self-funded health plans must upload a completed aggregate report using the template at the link below: Download Template Fully-insured commercial health plan must upload a completed aggregate report using the template at the link below: Download Template Please upload your completed report here:*Accepted file types: xls, xlsx, Max. file size: 2 MB.Please upload your completed report here:CAPTCHAUpon submission, you certify that the information you have entered in this assessment is true and complete to the best of your knowledge, and understand that you must notify the Office of Superintendent of Insurance (OSI) of any changes (e.g., total # of lives, contact information, etc.) at the following e-mail address: VPA.Data@state.nm.us. Pending review and approval by OSI and the New Mexico Department of Health, your submission fulfills the reporting requirement of the New Mexico Vaccine Purchasing Act for Fiscal Year 2021. Your survey is not complete until you click “Submit,” below. Following submission, you will be taken to a confirmation page you may print for your records. Questions? Contact NM OSI: VPA.Data@state.nm.us | (505) 322-2186