Outside Party CAS Access Request Form
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Outside Party CAS Access Request Form. This is a Ohio form and can be use in Industrial Commission Workers Comp.
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Tags: Outside Party CAS Access Request Form, IC-PW, Ohio Workers Comp, Industrial Commission
MAIL OR FAX TO:
OHIO INDUSTRIAL COMMISSION
INFORMATION TECHNOLOGY
30 W SPRING ST 8TH FL
COLUMBUS OH 43215
(614) 644-6595
TOLL FREE 877-218-4810
(614) 387-3900 - FAX
OUTSIDE PARTY I.C.O.N. ACCESS REQUEST FORM
INDUSTRIAL COMMISSION ONLINE NETWORK
BY REQUESTING THIS
ACCESS WE
UNDERSTAND...
Our request will create a
password that enables the
outside party indicated to
access detailed claim
information from the
Commission Adjudication
System.
Our designated contact
person will be responsible for
coordinating the password
among all parties using the
account.
Our designated contact
person will be the only
individual who will contact
I.C. Information Technology
regarding any changes to the
account, including address
information and
corresponding password.
By submitting this
documentation, along with
supporting letterhead, we are
confirming our account
information (name, address,
city, etc.).
ACCESS WILL NOT BE
GRANTED UNLESS SIGNED
BELOW
PLEASE PRINT ALL INFORMATION CLEARLY OR YOUR REQUEST MAY BE DELAYED
REPRESENTATIVE ID or RISK NUMBER:
i.e. 9
9
9
9
9
9
9
SIGNATURE
OIC 4002
-
9
9
9
IF YOU HAVE QUESTIONS REGARDING THE COMPLETION
OF THIS FORM, PLEASE CALL (614)644-6595.
CONTACT NAME:
CONTACT E-MAIL ADDRESS:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE NUMBER:
DATE
9
FIRM / COMPANY NAME:
PASSWORD CONVEYED:
-
NAME - PLEASE PRINT
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).
INTERNAL USE ONLY
VIA E-MAIL
VIA US POSTAL SERVICE
FAX NUMBER:
DATE:
12/11
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