State of Florida, Division of Administrative Hearings Office of the Judges of Compensation Claims 1203 Governors Square Boulevard, 6th Floor, Tallahassee Florida 32301 (850) 487-1911 PARTY'S VERIFIED REQUEST FOR COMPLETE EJCC ACCESS TO THE PARTY'S CASE. INSTRUCTIONS: First, register for eJCC at www.jcc.state.fl.us/eJCC. Next, fill this form in completely, sign it in the presence of a commissioned notary, show identification to the notary, and mail the original version of this completed form to the OJCC clerk at 1180 Apalachee Parkway, Suite A, Tallahassee, Florida 32301-4574. 1. OJCC case number:___________________ 2. Requestor's name:____________________________ 3. Requestor's address:_______________________________________________________________ 4. Requestor's phone number:___________________________ 5. Requestor's email address that is registered with eJCC:____________________________________ 6. Choose one of the following: ___ (check if applicable) I am the claimant in the OJCC case identified in line 1 of this form. ___ (check if applicable) I am an owner (sole proprietorship), general partner, officer, director, or managing agent for the following employer or carrier named as a party in the OJCC case identified in line 1 of this form ____________________________________________________ By signing below, I swear or affirm, under penalties of perjury, that the facts stated on this document are true and accurate. I agree that nothing gleaned or learned through eJCC access using my login and password will be disclosed in a manner that violates the privacy rights of any person or entity. Requestor's Signature _____________________________________ Country of _________________, State of _________________, County of _________________ The foregoing document was acknowledged before me this ____day of ____________, 20____, by ________________________________, who is personally known to me or who has produced identification and who took an oath/affirmed. The Identification Presented to the Notary Public is ___________________________________ Signature of Notary Public _________________________ (Notary Public Seal) Name of Notary Public ____________________________ My commission expires _________________ Party's Verified Request for Complete eJCC Access to the Party's Case American LegalNet, Inc. www.FormsWorkFlow.com