THIRD PARTY ADMINISTRATOR CHANGE FORM AN ADJUSTER OR THIRD PARTY ADMINISTRATOR HAS CHANGED Please complete all that apply: The following claims are assumed by the new TPA: List other information needed to identify claims assumed: Effective Date: Contact Person Please check one: The Primary Adjuster for the Insurer has changed Insurer's Name: Previous Adjuster: New Adjuster: New Adjuster City/State: E-Mail: The Employer's Primary Adjuster (Exception Adjuster) has changed Employer's Name: Insurer's Name(s): (list all) (Use another page if necessary) Previous Adjuster: New Adjuster: New Adjuster City/State: E-mail: Date: Signed: ____________________________ Printed Name & Title: Please PRINT and Sign. Mail to: Mona Hylton, DMU Employment Relations Division PO Box 8011 Helena, MT 59604-8011 Fax to: (406) 444-4140 Email to: mhylton@mt.gov If you have numerous changes, an alternative format may be accepted. Contact us for details. American LegalNet, Inc. www.FormsWorkFlow.com Past Present Future Phone Number: E-Mail: FEIN: FEIN: Phone Number: FEIN: FEIN: FEIN: Phone Number: DLI-ERD-WCC027 5/2014dje