Contact Registration Form | Pdf Fpdf Doc Docx | Florida

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Contact Registration Form | Pdf Fpdf Doc Docx | Florida

Contact Registration Form

This is a Florida form that can be used for Workers Comp.

Alternate TextLast updated: 5/1/2015

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Description

Office of Judges of Compensation Claims Contact Registration Form Pursuant to 60Q6.108(11)* the Office of Judges of Compensation Claims (OJCC) will publish in e-JCC a listing of all registered employers, carriers, and third-party administrators in Florida. Provision of the following information is required for this process. Any changes to this information can be accomplished by re-submitting this form and designating it as "amended." ( ) Initial Submission ( ) Amended Submission Date __________________________ Business name: _________________________________________________________ Check one: ( ) employer ( ) carrier ( ) TPA Business email address to which all litigation (LIT) pleadings, correspondence, notices and orders will be sent: ______________________________________________________________________ (For larger businesses, it may be appropriate that this address be used only for OJCC related e-mail, such as "OJCCmail@company.com" or "LITmail@company.com") Business U.S. Mail Address: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Business phone number for OJCC contact: ______________________________________________________________________ Name and title of person submitting this form: ______________________________________________________________________ Scan and submit this form by email to askojcc@doah.state.fl.us, or mail to Office of Judges of Compensation Claims, 1180 Apalachee Parkway, Suite A, Tallahassee, FL 32301. *Chapter 60, Florida Administrative Code 60Q6.108 Filing and Service (11) All employers, self-insurers, third-party administrators, and carriers shall register a single, general delivery, email address with the OJCC for receipt of all electronically served documents, including petitions for benefits. All employers, self-insurers, third-party administrators, and carriers shall register a single, general delivery, U.S. Mail address and a single telephone number with the OJCC. The e-JCC system will maintain a list of all registered companies and their e-mail addresses. Each such self-insurers, third-part administrators, and carrier shall be responsible for amending that e-mail address as necessary for it to remain current. Rulemaking Authority, 440.45(1)(a), (4). Law Implemented 440.192, 440.25(1), (4)(a), (4)(c), (4)(e), 440.45(1)(a), (4) FS. History-New 2-23-03, Amended 11-1-06, 20-31-10, 10-31-12, 11-10-14. American LegalNet, Inc. www.FormsWorkFlow.com

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