Florida > Workers Comp
Request For Assignment Of Case Number - Florida
| Request For Assignment Of Case Number Form. This is a Florida form and can be used in Workers Comp . |
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STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS REQUEST FOR ASSIGNMENT OF CASE NUMBER GROUNDS FOR REQUESTING CASE NUMBER (check one): ___ Settlement Requiring Approval by Judge of Compensation Claims ___ Settlement Requiring Approval by Judge of Compensation Claims as to Attorneys Fees Only ___ Modification of Prior Compensation Order ___ Claim for Reimbursement from Special Disability Trust Fund ___ Third-Party Claim ___ Claim Limited to Attorneys Fees or Taxable Costs ___ Other (cite statutory authority:___________________________________ __________________) NAME OF REQUESTOR ___________________________ TITLE/CAPACITY/CLIENT ________________________________ ADDRESS: ___________________________________ TELEPHONE: (_____)_ ____-________ INFORMATION PERTAINING TO THE CLAIM OR REQUEST (Furnish all that apply) : EMPLOYEE: ______________________ EMPLOYER: ______________________ CARR IER: ______________________ ADDRESS: ______________________ ADDRESS: ______________________ ADDR ESS: ______________________ ______________________ ______________________ ______________________ TELEPHONE: (_____)_____-_______ TELEPHONE: (_____)_____-_______ TELEPHONE: (_____)_____-_______ ________________________________________________________________________ __________________________________ SOCIAL SECURITY NO: ( required ) ACCIDENT DATE: COUNTY: __________________ ________-______-_________ ______/______/______ S TATE: __________________ or, CHECK IF ALIEN STATUS: ____ One Case Assigned per Acci dent Date (required) ________________________________________________________________________ __________________________________ EMPLOYEE/CLAIMANT EMPLOYER/CARRIER: ATTORNEY: ___________________________________ ATTORNEY: _________ ___________________________ ADDRESS: ___________________________________ ADDRESS: _________ ___________________________ ___________________________________ _________ ___________________________ TELEPHONE: (_____)_____-_________ TELEPHONE: (_____ )_____-_________ FLORIDA BAR NO.__________________ FLORIDA BAR NO._____ _____________ ________________________________________________________________________ ___________________________ IF THIS IS A THIRD-PARTY CLAIM, IDENTIFY THE ADDITIONAL PARTIES BELOW. IDENTITY OF THIRD PARTY _______________________ IDENTITY OF ANY OTHE R PARTY ___________________ PARTYS ADDRESS________________________________ PARTYS ADDRESS_____ ___________________________ _____________________________________ __________ ___________________________ ATTORNEY: _____________________________________ ATTORNEY: __________ ___________________________ ATTORNEYS ADDRESS: ___________________________ ATTORNEYS ADDRESS: ___________________________ ___________________________ ___________________________ TELEPHONE: (_____)_____-_________ TELEPHONE: (_____ )_____-_________ FLORIDA BAR NO.__________________ FLORIDA BAR NO._____ _____________ I hereby certify that the information contained herein is accurate to th e best of my information, knowledge and belief. Signature of Requestor:__________________________________________ DATE: ________________ OJCC Clerks Office Request for Assignment of Case Number filing: Post Office Box 6410, Tallahassee, Florida 32314-6410 ?? (850) 487-1911 Extension 106 SUNCOM 277-1911 ?? www.jcc.state.fl.us E mail Ann_Cole@doah.state.fl.us American LegalNet, Inc. www.USCourtForms.com
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