Representative Employer Change Of Address {EMP-2}

REPRESENTATIVE OR EMPLOYER CHANGE OF ADDRESS/CONTACT Check one of the options below. This is a change of contact information for a: Representative Employer Rep ID # Risk # Current Contact Information on File with the Industrial Commission Name Address City, State, Zip, Country Telephone Fax Email New Contact Information to be Changed Name Address City, State, Zip, Country Telephone Fax Email Company/Firm Name Company/Firm Name Date Change is Effective (mm/dd/yyyy) These changes are authorized by the following individual with the understanding that the new address will impact the mailing of all correspondence from the Ohio Industrial Commission. Print Name Signature Date Fax the completed form to the Ohio Industrial Commission at (614) 728-7004. If you have questions contact the IC Helpdesk at (614) 644-6595. FOR OHIO INDUSTRIAL COMMISSION USE ONLY Address Changed By Date An Equal Opportunity Employer and Service Provider Timely, impartial resolution to workers' compensation appeals American LegalNet, Inc. www.FormsWorkFlow.com IC EMP2 OIC 4001 Rev. (09/16)