STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS REQUEST FOR ASSIGNMENT OF CASE NUMBER GROUNDS FOR REQUESTING CASE NUMBER: ___ SETTLEMENT REQUIRING APPROVAL BY JUDGE OF COMPENSATION CLAIMS (OF SETTLEMENT ITSELF OR OF ATTORNEY FEES). ___ MODIFICATION OF PRIOR COMPENSATION ORDER ___ CLAIM FOR REIMBURSEMENT FROM SPECIAL DISABILITY TRUST FUND ___ THIRD-PARTY CLAIM ___ CLAIM LIMITED TO ATTORNEY'S FEES OR TAXABLE COSTS ___ OTHER (CITE STATUTORY AUTHORITY:_________________________________________________________________________________________________) REQUESTOR'S NAME: TITLE/CAPACITY/CLIENT: ADDRESS: TELEPHONE NO.: EMPLOYEE: FLORIDA BAR NO. (if attorney): EMPLOYEE'S SOCIAL SECURITY NO.: ADDRESS: TELEPHONE: or attach a VERIFIED MOTION FOR SUBSTITUTE IDENTIFICATION NUMBER (form available on the OJCC website at www.jcc.state.fl.us) EMPLOYER: CARRIER: ADDRESS: ADDRESS: TELEPHONE: TELEPHONE: DATE OF ACCIDENT (disablement date if occupational disease): ACCIDENT COUNTY: ACCIDENT STATE: IF THIS IS A THIRD-PARTY CLAIM, SPECIAL DISABILITY TRUST FUND CLAIM, OR ANY OTHER CLAIM INVOLVING ADDITIONAL PARTIES, THEY MUST BE CLEARLY IDENTIFIED AS SUCH IN THE ACCOMPANYING PLEADINGS SETTING FORTH THE CLAIM, AND NAMES, ADDRESSES, AND TELEPHONE NUMBERS MUST BE PROVIDED FOR EACH. I hereby certify that the information contained herein is accurate to the best of my information, knowledge and belief. ____________________________________________ Requestor's Signature Date THE OFFICE OF THE JUDGES OF COMPENSATION CLAIMS’ COLLECTION AND USE OF SOCIAL SECURITY NUMBERS Disclosure of the employee’s Social Security Number (SSN) is voluntary. An employee or claimant who does not have or declines to provide the employee’s SSN must file a verified motion for assignment of substitute identification number along with the initial Petition for Benefits or Request for Assignment of Case Number in accordance with Fla. Admin. Code 60Q-6.105(4). The employee’s SSN will be used to uniquely identify the employee in the Office of the Judges of Compensation Claims (OJCC) case management system, ascertain a claimant’s child support obligations before approving any lump sum settlement, and exchange information between the OJCC and the Division of Workers’ Compensation. The employee’s SSN may also be used by the employer and carrier named on the Petition for Benefits or Request for Assignment of Case Number to identify the employee. SSN’s are confidential and exempt from public disclosure. It is the express policy of the OJCC to prohibit the disclosure of SSN’s by the OJCC or any of its employees, except the SSN will be disclosed by the OJCC for the following reasons: (1) in response to a legitimate inquiry from a state or federal agency in connection with matters within its jurisdiction; (2) if so ordered by a court of competent jurisdiction, pursuant to the terms of such order; and (3) to a commercial entity in response to a request in accordance with §119.071(5)(a)(7), Florida Statutes. OJCC Form RACN (Revised 1-9-2008) American LegalNet, Inc. www.FormsWorkflow.com