Request For Assignment Of Case Number

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