For Clerk’s Use Only CURRENT EMPLOYER, OR OTHER PAYOR INFORMATION THIS FORM MUST BE COMPLETED FOR: AN ORDER OF ASSIGNMENT ORDER TO STOP AN ORDER OF ASSIGNMENT NOTIFICATION OF A CHANGE OF EMPLOYER or OTHER PAYOR CASE NUMBER: __________________________ ATLAS NUMBER: ________________________ PAYOR NAME: ________________________________________ (PERSON RESPONSIBLE TO MAKE PAYMENTS) LIST ONLY THE EMPLOYER OR OTHER PAYOR’S NAME AND PAYROLL ADDRESS WHERE THE ORDER OF ASSIGNMENT OR STOP ORDER SHOULD BE MAILED. CURRENT EMPLOYER / OTHER PAYOR NAME: __________________________________________________ CURRENT EMPLOYER / OTHER PAYOR PAYROLL / FINANCIAL DEPARTMENT ADDRESS: ___________________________________________________________________________________________ CITY: ______________________________ STATE: ___________________________ ZIP: _________________ EMPLOYER / OTHER PAYOR TELEPHONE: _______________________________________ EMPLOYER / OTHER PAYOR FAX: _______________________________________ ___________________________________________________________________________________________ FOR COURT USE ONLY. DO NOT WRITE BELOW THIS LINE. WA/FSC WA/LOG ID _____________________________________________ TYPE OF W/A _____________________________________________ DATE _____________________________________________ AMOUNT OF ORDER _____________________________________________ EMPLOYER STATUS _____________________________________________ ENTERED BY _____________________________________________ NEW W/A ____________________ SUB ____________________ AG ____________________ DCSE ____________________ 5/5/09 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com