BI-CAN 01/06 Change of Address Notification Return completed form to: BrickStreet Mutual Insurance P. O. Box 3151 Charleston, WV 25332-3151 1. Claimant’s Name 2. Claim Number 3. Social Security Number 4. Date of Injury 5. Old Address (Street or P.O. Box, City, State, Zip) 6. New Address (Street or P.O. Box, City, State, Zip) 7. New County 8. New Phone Number (include area code) 9. Have you ever been, or are you currently being represented by an attorney in this claim? Yes No If yes, give name and address of attorney. Claimant’s Signature Date BrickStreet Mutual Insurance  P.O. Box 3151  Charleston, WV  25332-3151 American LegalNet, Inc. www.USCourtForms.com