Outside Party ICON Access Request Form {IC-PW}

MAIL OR FAX TO: OHIO INDUSTRIAL COMMISSION INFORMATION TECHNOLOGY INDUSTRIAL COMMISSION ONLINE NETWORK 30 W SPRING ST 8TH FL COLUMBUS OH 43215 (614) 644-6595 PLEASE PRINT ALL INFORMATION CLEARLY OR YOUR REQUEST MAY BE DELAYED. TOLL FREE 877-218-4810 THIS FORM CAN BE FILLED OUT ONLINE BUT WILL NEED PRINTED TO BE SIGNED. (614) 387-3900 - FAX OUTSIDE PARTY I.C.O.N. ACCESS REQUEST FORM BY REQUESTING THIS ACCESS WE UNDERSTAND... Our request will create a password that enables our party to access claim information from I.C.O.N. REPRESENTATIVE ID or POLICY/RISK NUMBER: NOTE: Not all boxes may be needed NOTE: IF YOU ARE A SELF-INSURED OR PUBLIC EMPLOYER AND WOULD LIKE ONE PASSWORD FOR ALL PLANT LOCATIONS, PLEASE INDICATE 999 RATHER THAN THE SPECIFIC PLANT NUMBER (eg. 20001350-999). - Our designated contact person will be responsible for FIRM / COMPANY NAME: coordinating the password among all parties using the account. CONTACT NAME: ACCESS WILL NOT BE GRANTED UNLESS SIGNED BELOW NAME - PLEASE PRINT CONTACT E-MAIL ADDRESS: ADDRESS: SIGNATURE DATE By submitting this form, ALONG WITH A SIGNED LETTERHEAD, we are confirming our account information (name, address, city, etc.). If you have any questions regarding the completion of this form, please call (614) 644-6595 or 877-218-4810. CITY: STATE: ZIP CODE: - PASSWORD CONVEYED: VIA E-MAIL FAX NUMBER: VIA US POSTAL SERVICE PHONE NUMBER: OIC 4002 American LegalNet, Inc. www.FormsWorkFlow.com 02/16