Claimant Name And Address Form {OC-966}

OC-966 - CLAIM NAME AND ADDRESS FORM. This form is used in connection with a Workers' Compensation case to notify the appropriate parties of changes to a claimant’s personal information, such as name, mailing address, phone number, or email address. It includes sections to record both the new and previous claimant information for proper identification and update. The form is intended to be shared with the workers’ compensation insurance carrier, self-insured employer, or employer but is not submitted to the Workers’ Compensation Board itself. It includes spaces for insurer and attorney details, and requires certification by the attorney that the notice has been properly transmitted to the appropriate parties. The insurer is then responsible for submitting the appropriate electronic data interchange (EDI) update to reflect the changes in the Board’s case file. www.FormsWorkflow.com