Montana > Workers Compensation
Adjuster Change Form - Montana
| Adjuster Change Form Form. This is a Montana form and can be used in Workers Compensation . |
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THIRD PARTY AGENT CHANGE FORM AN ADJUSTER HAS CHANGED!! (Use your TAB key to fill out.) Please check all that apply: The following claims are assumed by the new TPA: List other information needed to identify claims assumed: Effective Date: Contact Person Please check one: The Primary Adjuster for the Insurer has changed Insurer's Name: Previous Adjuster: New Adjuster: New Adjuster City/State: FEIN: Phone Number: FEIN: Phone Number: Past Present Future The Employer's Primary Adjuster (Exception Adjuster) has changed Employer's Name: Insurer's Name: Previous Adjuster: New Adjuster: City Phone Number: Date: Signed: ____________________________ Title: Please PRINT and Sign. Mail to: Kelli Street, DMU Employment Relations Division PO Box 8011 Helena, MT 59604-8011 (406) 444-4140 kstreet@mt.gov FEIN: FEIN: FEIN: Fax to: Email to: American LegalNet, Inc. www.FormsWorkFlow.com
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