California > Workers Comp > General
EDEX Client List - California
| EDEX Client List Form. This is a California form and can be used in General Workers Comp . |
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EDEX CLIENT LIST Subscriber must provide the name and address of each of its clients (those filing notices of liens OR inquiries via EDEX). An identification number will be assigned to each client for use in the EDEX process; each transmission must include the proper client identification number. Certain clients must also sign an EDEX Client Acknowledgment of Legal Constraints on Access to Information and Use of Information. A client must execute an EDEX Client Acknowledgment if the Subscriber will be making any inquiry on behalf of the client regarding a case in which the client is neither a lien claimant nor a party. Subscriber, check box if applicable: Subscriber does not have "clients" but will be making inquiries and/or filing notices of liens on its own behalf and requests that it be assigned its own client identification number. (List Subscriber as "Client" below.) ========================================================================================== SUBSCRIBER NAME: __________________________________________________________________ ACCOUNT NUMBER (If known) __________________________________________________________________ ========================================================================================== CLIENT ID # ____ ____ ____ ____ ____ [DWC USE ONLY] Lien Claimant CLIENT NAME: CLIENT ADDRESS: Case Party Other* __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ PHONE # (_____)________________________ FAX: (____)_________________________ ========================================================================================== CLIENT ID # ____ ____ ____ ____ ____ [DWC USE ONLY] Lien Claimant CLIENT NAME: CLIENT ADDRESS: Case Party Other* __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ PHONE # (_____)________________________ FAX: (____)_________________________ ========================================================================================== CLIENT ID # ____ ____ ____ ____ ____ [DWC USE ONLY] Lien Claimant CLIENT NAME: CLIENT ADDRESS: Case Party Other* __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ PHONE # (_____)________________________ FAX: (____)_________________________ ========================================================================================== * A signed EDEX Client Acknowledgment must be attached for each client designated as "other". ATTACH ADDITIONAL SHEETS AS NECESSARY __________________________________________ Subscriber Signature / Title Date EDEX Client List Rev. 6/2006 1 American LegalNet, Inc. www.USCourtForms.com
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