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This is a West Virginia form that can be used for Workers Comp.
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BI-CAN 03/14 Change of Address Notification 1. Claimant's Name Return completed form to: BrickStreet Insurance P. O. Box 3151 Charleston, WV 25332-3151 2. Claim Number 3. Social Security Number 4. Date of Injury 5. Old Address (Street or P.O. Box, City, State, Zip) 6. New Address (Street or P.O. Box, City, State, Zip) 7. New County 8. New Phone Number (include area code) 9. Have you ever been, or are you currently being represented by an attorney in this claim? If yes, give name and address of attorney. Yes No Claimant's Signature Date BrickStreet Mutual Insurance NorthStone Insurance PinnaclePoint Insurance SummitPoint Insurance American LegalNet, Inc. www.FormsWorkFlow.com
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