Subscriber Change Form

NJ Division of Workers' Compensation COURTS on-line: Subscriber Change Form It is the COURTS on-line Contact Person's responsibility to advise the Division whenever there has been a change in information pertaining to one of their COURTS on-line subscribers. This form can be used to report the following changes: subscriber name, subscriber address, telephone number, e-mail address and electronic filing access level. · If the change involves an e-mail account that is also used for the Electronic Calendar program, do you want us to automatically update the e-mail that is used for that program to the new one supplied below? YES NO If your company's registered address or name has changed, this form should not be used to report the change. The change must be sent to us in writing on company letterhead. subscriber_change071813_i · Please indicate the subscriber's existing name and e-mail below and any updated information pertaining to that subscriber. If there has been a subscriber name change, please indicate both the old and the new name. I. Subscriber Information: Name (Required): New Name (If Changed): Company Name: (Required) Street Address City, State, ZIP Telephone #: Is the above Subscriber also the Contact Person? Fax #: YES NO E-Mail address: (Required) New E-Mail address: (If Changed) ELECTRONIC FILING SECTION ­ Please select new access level if this information is being changed BASIC LIMITED FULL Law Firms only - Subscribers will be able to receive notices of electronically filed legal pleadings, data enter and save information into pre-formatted templates but they will not be able to electronically file any legal documents. If Law Firm - this access level will give subscribers full rights to receive and file legal pleadings electronically. If Carriers ­ this access level will allow you to receive pleadings, to designate respondent counsel electronically and to e-file Applications for Informal Hearings. Subscribers will not be able to electronically receive or submit legal pleadings on behalf of the firm/company. This is the default access level assigned to all subscribers. ** Note - If Limited or Full Access is selected for at least one subscriber, this company will receive notice of e-filed documents solely through the COURTS on-line website and not through US Mail. II. Courts On-Line Contact Person Signature: I am the Contact Person for and I am submitting the above changes to the Division of Workers' Compensation so that they can update their records. Date: Signature: Contact Person Name and Title PLEASE MAIL COMPLETED FORM TO: Division of Workers' Compensation, PO Box 381, Trenton, NJ 08625-0381, Attn: Technical Support Unit YOU CAN ALSO FAX THIS FORM TO: (609) 292-3758, attn: Technical Support Unit American LegalNet, Inc. www.FormsWorkFlow.com