INDUSTRIAL COMMISSION OF OHIOCHANGE OF AN EMPLOYER'S GLOBAL REPRESENTATIVE(NOTE: A GLOBAL Representative would be an individual or Firm which represents the Employer on ALL claims. If representation is on a claim by claim basis, please file the appropriate R1 card.)EMPLOYER:--( )All PlantsRISK #PLANT CODEEMPLOYER NAMEThe address associated with each risk is determined by the RiskDOING BUSINESS ASAND the Plant Code.ADDRESS--0...would be Chrysler Motors Corporation, Warren MI 20002708--3CITYSTZIP...would be Chrysler Motors Corporation, Van Wert, OH 20002708--5FOREIGN COUNTRY EXAMPLE:20002708...would be Chrysler Motors Corporation, Perrysburgh, OHACTIVATEDISMISSGLOBAL REPRESENTATIVE(S):Rep.#NameEffective DateGLOBAL REPRESENTATIVE(S):Rep.#NameEffective DateGLOBAL REPRESENTATIVE(S):Rep.#NameEffective DateONLY THE EMPLOYER IS AUTHORIZED TO SIGN THIS FORM.AUTHORIZED BY:DATE:EMPLOYER:--( )All PlantsRISK #PLANT CODEEMPLOYER NAMEDOING BUSINESS ASThe address associated with each risk is determined by the RiskAND the Plant Code.ADDRESSEXAMPLE:20002708--0ZIPSTCITY...would be Chrysler Motors Corporation, Warren MI 20002708--3FOREIGN COUNTRY...would be Chrysler Motors Corporation, Van Wert, OH 20002708--5...would be Chrysler Motors Corporation, Perrysburgh, OHACTIVATEDISMISSGLOBAL REPRESENTATIVE(S):Effective DateNameRep.#GLOBAL REPRESENTATIVE(S):Effective DateNameRep.#GLOBAL REPRESENTATIVE(S):Effective DateNameRep.#ONLY THE EMPLOYER IS AUTHORIZED TO SIGN THIS FORM.DATE:AUTHORIZED BY:FOR INTERNAL USE ONLYDate:Rep Changed By:EMP -1OIC 4000 (Rev. 7/99)2002 © American LegalNet, Inc.
|
Get this form for FREE as a print-only pdf
