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NJ Division of Workers' Compensation COURTS on-line: Subscriber Change Form

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It is the COURTS on-line Contact Person's responsibility to advise the Division whenever there has been a change in information pertaining to one of their COURTS on-line subscribers. This form can be used to report the following changes: subscriber name, subscriber address, telephone number, e-mail address and electronic filing access level. If your firm's registered address or name has changed, this form should not be used to report the change. The change must be sent to us in writing on company letterhead. Please indicate the subscriber's existing name and e-mail below and any updated information pertaining to that subscriber. If there has been a subscriber name change, please indicate both the old and the new name. Subscriber Information: Name (Required): New Name (If Changed): Firm Name (Required) Street Address City, State, ZIP Telephone #: Fax #: E-Mail address: (Required) New E-Mail address:

ELECTRONIC FILING ­ Please select new access level if this information is being changed BASIC Subscribers will not be able to electronically receive or submit legal pleadings on behalf of the firm. This is the default access level assigned to all subscribers. Law Firms only - Subscribers will be able to receive notices of electronically filed legal pleadings, data enter and save information into pre-formatted templates but they will not be able to electronically file any legal documents. If Law Firm - this access level will give subscribers full rights to receive and file legal pleadings electronically. If Carriers ­ this access level will allow you to receive pleadings and to designate respondent counsel electronically.

LIMITED

FULL

** Note - If Limited or Full Access is selected for at least one employee, this firm will receive notice of e-filed documents solely through the COURTS on-line website and not through US Mail. Courts On-Line Contact Person Signature: I am the Contact Person for the Division of Workers' Compensation so that they can update their records. and am submitting the above changes to

Date:

Signature:

Contact Person Name and Title

PLEASE MAIL COMPLETED FORM TO: Division of Workers' Compensation, PO Box 381, Trenton, NJ 08625-0381, Attn: Technical Support Unit YOU CAN ALSO FAX THIS FORM TO: (609) 292-3758, attn: Technical Support Unit