Ohio > Workers Comp > Industrial Commission
Outside Party CAS Access Request Form IC-PW - Ohio
| Outside Party CAS Access Request Form Form. This is a Ohio form and can be used in Industrial Commission Workers Comp . |
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MAIL OR FAX TO: OUTSIDE PARTY I.C.O.N. ACCESS REQUEST FORM INDUSTRIAL COMMISSION ONLINE NETWORK BY REQUESTING THIS ACCESS WE UNDERSTAND... Our request will create a password that enables the outside party indicated to access detailed claim information from the Commission Adjudication System. Our designated contact person will be responsible for coordinating the password among all parties using the account. Our designated contact person will be the only individual who will contact I.C. Information Technology regarding any changes to the account, including address information and corresponding password. By submitting this documentation, along with supporting letterhead, we are confirming our account information (name, address, city, etc.). ACCESS WILL NOT BE GRANTED UNLESS SIGNED BELOW PLEASE PRINT ALL INFORMATION CLEARLY OR YOUR REQUEST MAY BE DELAYED OHIO INDUSTRIAL COMMISSION INFORMATION TECHNOLOGY 30 W SPRING ST 8TH FL COLUMBUS OH 43215 (614) 644-6595 TOLL FREE 877-218-4810 (614) 387-3900 - FAX REPRESENTATIVE ID or RISK NUMBER: NOTE: IF YOU ARE A SELF-INSURED OR PUBLIC EMPLOYER AND WOULD LIKE ONE PASSWORD FOR ALL PLANT LOCATIONS, PLEASE INDICATE 999 RATHER THAN THE SPECIFIC PLANT NUMBER (eg. 20001350-999). i.e. 9 9 9 9 9 9 9 9 - 9 9 9 IF YOU HAVE QUESTIONS REGARDING THE COMPLETION OF THIS FORM, PLEASE CALL (614)644-6595. FIRM / COMPANY NAME: CONTACT NAME: CONTACT E-MAIL ADDRESS: ADDRESS: CITY: STATE: ZIP CODE: - PASSWORD CONVEYED: VIA E-MAIL FAX NUMBER: VIA US POSTAL SERVICE NAME - PLEASE PRINT PHONE NUMBER: SIGNATURE OIC 4002 DATE INTERNAL USE ONLY DATE: 12/11 American LegalNet, Inc. www.FormsWorkFlow.com
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