ࡱ> X[W{ Lbjbjzz ER  fffffzzz8|.lz#0l8"######$s%%($#]fLLL$#ff4#HHHL:ff"HL"HHV!@"'R! "#0#!0(("(f"LLHLLLLL$#$#LLL#LLLL(LLLLLLLLL ,: NJ Division of Workers Compensation COURTS on-line: Subscriber Change Form subscriber_change071813_i It is the COURTS on-line Contact Persons 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 the change involves an e-mail account that is also used for the Electronic Calendar program, do you want us to automatically update the e-mail that is used for that program to the new one supplied below?  FORMCHECKBOX  YES  FORMCHECKBOX  NO If your companys 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 subscribers 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. I. Subscriber Information: Name (Required): FORMTEXT      E-Mail address: (Required) FORMTEXT      New Name (If Changed): FORMTEXT      New E-Mail address: (If Changed) FORMTEXT      Company Name: (Required) FORMTEXT      Street Address FORMTEXT      City, State, ZIP FORMTEXT      Telephone #: FORMTEXT      Fax #: FORMTEXT       Is the above Subscriber also the Contact Person?   FORMCHECKBOX  YES  FORMCHECKBOX  NO ELECTRONIC FILING SECTION  Please select new access level if this information is being changed  FORMCHECKBOX  BASIC Subscribers will not be able to electronically receive or submit legal pleadings on behalf of the firm/company. This is the default access level assigned to all subscribers.  FORMCHECKBOX  LIMITED 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.  FORMCHECKBOX  FULL 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, to designate respondent counsel electronically and to e-file Applications for Informal Hearings. ** Note - If Limited or Full Access is selected for at least one subscriber, this company will receive notice of e-filed documents solely through the COURTS on-line website and not through US Mail. II. Courts On-Line Contact Person Signature: %3@Aҽm]J:-hh}OJQJaJhh}>*CJOJQJaJ%hht956>*CJOJQJaJhs>56>*CJOJQJaJ%hhtd56>*CJOJQJaJ%hh}56>*CJOJQJaJ(hs>hj>*B* CJOJQJaJphp(hs>hp>*B* CJOJQJaJphp(hs>h}>*B* CJOJQJaJphp+hs>h}6>*B* CJOJQJaJphp.hs>h}>*B* CJOJQJ\]aJphp %    }xrrjaY & Fgdu(^gdJ( & FgdJ(^$a$rkd$$Ifl4*+  04 l` af4p $Ifgdp$If O ]  ? C Q l n ŲzfV?fV-jhhJ(5KHOJQJUhhhJ(5KHOJQJh'jhhJ(5KHOJQJUhhJ(B* CJOJQJ\ph'hs>hJ(5B* CJOJQJ\ph'hJ(hJ(>*B* CJOJQJ\ph$hs>hJ(B* CJOJQJ\phhu(5CJOJQJhh}56CJOJQJhh}5CJOJQJ!hh}B*CJOJQJph      % _ b 𫛈uaN@2@2hh-5CJOJQJhh}5CJOJQJ$hs>hu(B* CJOJQJ\ph'hs>h}5>*B* CJOJQJph$hs>hp5B* CJOJQJph$hs>h}5B* CJOJQJphhJ(5B* CJOJQJph$hs>hJ(B* CJOJQJ\ph'jhJ(5KHOJQJUh!jhJ(5KHOJQJUhhJ(5KHOJQJhhJ(5B*CJOJQJph ~ 4 6 n p |  $Ifgd2 2$$d%d&d'd-DM NOPQa$gdt9$a$^gdu(  $ | ~ 2 4 6 < n p | ~ 񻪙ugZLZ;!hh}B*CJOJQJphhh}6CJOJQJhh}CJOJQJhh}5CJOJQJ$hh}5B*CJOJQJph!hh}B* CJOJQJphp!hhpB* CJOJQJphp!hh}B*CJOJQJphhh}CJOJQJhhr5CJOJQJhr5CJOJQJhh}5>*CJOJQJhh}5CJOJQJ   ꔁn`G6!hh}B*CJOJQJph0jhhuB*CJOJQJUphhh-6CJOJQJ$hh}5B*CJOJQJph$hh-5B*CJOJQJph!hh}/ B*CJOJQJph5jhhcB*CJOJQJUmHnHphu0jhhuB*CJOJQJUph!hhyB*CJOJQJph*jhhyB*CJOJQJUph0Lt $Ifgd2ukdj$$Ifl4P\z*4 laf40JLNbdfprtкudкKud:!hh-B*CJOJQJph0jzhhuB*CJOJQJUph!hh}/ B*CJOJQJph5jhhcB*CJOJQJUmHnHphu0jhhuB*CJOJQJUph!hhyB*CJOJQJph*jhhyB*CJOJQJUph$hh-5B*CJOJQJphhh-6CJOJQJhh-5CJOJQJ:<w*Lkd$$IflP0*#4 la $Ifgd2 $Ifgd2ukd$$Ifl4P\z*4 laf4(*,68<Z\p漫wfP?!hh}/ B*CJOJQJph*jhh}/ B*CJOJQJUph!hh}B*CJOJQJph5jhhcB*CJOJQJUmHnHphu0jhh!GjB*CJOJQJUph!hhGVB*CJOJQJph*jhhGVB*CJOJQJUph'hh}56B*CJOJQJphhh}CJOJQJhhpCJOJQJ<ZCLkd$$IflP0*#4 la $Ifgd2Lkd$$IflP0*#4 la $Ifgd2$$If^a$gd2prt~ѶѥчnѶѥ[H[2*jhhyB*CJOJQJUph$hh=5B*CJOJQJph$hh-5B*CJOJQJph0j<hhuB*CJOJQJUph!hh}/ B*CJOJQJphhh}CJOJQJ!hh}B*CJOJQJph5jhhcB*CJOJQJUmHnHphu*jhh}/ B*CJOJQJUph0j\hhuB*CJOJQJUph "68:DFHJտgVF5F!hhu(B*CJOJQJphhu(5B*CJOJQJph!hh}/ B*CJOJQJph0jhhuB*CJOJQJUph$hh-5B*CJOJQJph!hh-B*CJOJQJph5jhhcB*CJOJQJUmHnHphu*jhhyB*CJOJQJUph0jhhuB*CJOJQJUph!hhyB*CJOJQJph HJL}tk $Ifgd@# $Ifgdu(xkd$$Ifl4P\xVx4 laf4yts> $Ifgd2 @۴r_N=0hh}CJOJQJ!hh}B*CJOJQJph!hhu(B*CJOJQJph$h@#hu(5B*CJOJQJphhu(5B*CJOJQJph'j h@#5KHOJQJUh!jh@#5KHOJQJUhh@#5KHOJQJhh@#5B*CJOJQJph-jhh@#5KHOJQJUhhh@#5KHOJQJh'jhh@#5KHOJQJUhM $^a$gdp $`^``a$ `1$^`` $a$Rkd $$Ifl4w0x x4 laf4ytL @P px̸scsUsG4$jhh}/ 5CJOJQJUhh}5CJOJQJhhpKHOJQJhhh}>*KHOJQJhhh}KHOJQJhhh}5KHOJQJh-j hhY15KHOJQJUhhh}/ 5KHOJQJh'jhh}/ 5KHOJQJUhhh}5>*CJOJQJhh2+CJOJQJhh}CJOJQJhrCJOJQJLMPXq5?񺭟񺭟|oo_Ohhp5CJOJQJ\hh}5CJOJQJ\hh3CJOJQJhhpCJOJQJ*j hhY15CJOJQJUhh}>*CJOJQJhh}CJOJQJhh}5CJOJQJ$jhh}/ 5CJOJQJU*jn hhY15CJOJQJUhh}/ 5CJOJQJ?FM@8@:@P@p@r@|@~@@@@rAtA±wfwOw>f!hhpB*CJOJQJph,hhB*CJOJQJmHnHphu!hhcB*CJOJQJph*jhhjB*CJOJQJUph!hhjB*CJOJQJphU!hh}B*CJOJQJph!hh}B* CJOJQJphp!hhpB* CJOJQJphphh}CJOJQJhhp5CJOJQJ\hh}5CJOJQJ\8@@@ $If^gdGY L$If^gdGY ~ r$If]rgdp $`^``a$2$$d%d&d'd-DM NOPQa$gdt9I am the Contact Person for REF Text5 \* MERGEFORMAT  and am submitting the above changes toto the Division of Workers Compensation so that they can update their records. Date: FORMTEXT      Signature:  FORMTEXT      @@pArAtAw-($a$Jkd $$Ifl** t*644 lap ytp $$Ifa$gdGY|kdV $$Ifl(F~ .* \ t*6    44 lapytptAvAAAAAAAAHkd $$Ifl r B*"8 t644 lap2ytGY $IfgdGYtAAAAAAAAAAAAAAAABLLL L>L?LLLLLyeQeQeIjh:gU'hh-5B* CJOJQJ\ph'hh}5B* CJOJQJ\phhh=CJOJQJhh}/ 6CJOJQJU'jy hh}/ CJOJQJUhhCCJOJQJ,jhhcCJOJQJUmHnHu'j@ hh}/ CJOJQJU!jhh}/ CJOJQJUhh}/ CJOJQJAAAAAAAAAHkd $$Ifl3r B*"8 t644 lap2ytGY $IfgdGYABLL LH?$`a$kd$$Iflr B*"8 t644 lap2ytGY $IfgdGYContact Person Name and Title PLEASE MAIL COMPLETED FORM TO: Division of Workers Compensation, PO Box 381, Trenton, NJ 08625-0381, Attn: Technical Support Unit YOU CAN ALSO FAX THIS FORM TO: (609) 292-3758, attn: Technical Support Unit     L?LLLLLLLLLLLLL2$$d%d&d'd-DM NOPQa$gd= LLLLLLLLL'hh}5B* CJOJQJ\phjh:gUh:gC0P/R :ps>BP/ =!"#@$@% Dp$$If!vh#v+:V l4  05+4` f4p tDeCheck1hDetD(Text1tDText2$$If!vh#v#v#v#v:V l4P,5555/ / 4af4tD(Text3tDText4$$If!vh#v#v#v#v:V l4P,5555/ / 4af4tD@Text5\$$If!vh#v#v#:V lP,55#4atDText6j$$If!vh#v#v#:V lP,55#/ 4atDText7j$$If!vh#v#v#:V lP,55#/ 4atDText8tDText9$$If!vh#v#v#v#v:V l4Px,5555/ / 4af4yts>tDeCheck1hDev$$If!vh#v#v :V l4wx,55 / 4af4ytLtDeCheck1tDeCheck2tDeCheck3$$If!vh#v #v#v\ :V l( t*65 55\ / pytpR$$If!vh#v*:V l t*65*p ytpjD$$If!vh#v#v#v#vC#v:V l t65"55585/ / p2ytGYvDText17$$If!vh#v#v#v#vC#v:V l3 t65"55585/ / p2ytGY$$If!vh#v#v#v#vC#v:V l t65"55585/ p2ytGY^ h2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH D`D Normal1$CJ_HhmH sH tH D@D  Heading 1$$@&a$ 5B*CJH@H  Heading 2$$@&a$ 5>*B*CJL@L  Heading 3$$ @&a$ 5B*CJB@B  Heading 4$$@&a$5CJD@D  Heading 5$$@&a$ 5>*CJJ@J  Heading 6$$ @&a$6CJR@R  Heading 7$$@&^a$5B*\phD@D  Heading 8$@&5B*CJphD @D  Heading 9 $$@&a$ 5>*CJDA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List <& < Footnote Reference44 Header  !4 4 Footer  !DB@"D Body Text$ a$6CJ>P@2> Body Text 2  CJ<Q@B< Body Text 3$a$CJjSj }/ Table Grid7:V0*W`a* u(`Strong5\PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] R  p@?tALL #( <@tAAA LL !"$%'  &28[gm"Yiw ! ' G$G$FFFFFFFFFG$G G$G$G$FF@ @H 0(  0(  B S  ? Text1Text2Text3Text4Text5Text6Text7Text8Text9Check1Check2Check3Text17'\   9n# Q S 33n>?Gw  (   n>Gw  (   "npu Lz4_bFhh^h`B*CJOJQJo(0^`0o(.h^`OJQJo(hHh^`OJQJ^Jo(hHohp^p`OJQJo(hHh@ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohP^P`OJQJo(hHpu 4_b         .-@#2+GY}/ b?2=J(\C-t1t9+:s>SHEPGVtd:g!GjY1yjCU|N:u(W3pu r-}LcBJ)T*9$l @X @ $@@@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7@Cambria;Wingdings?= *Cx Courier NewA$BCambria Math" h)֓ʃ   ș 2 3Q HX?U|*!xx  Shravani KosnikKosnik, Shravani   Oh+'0 $ D P \ ht| Shravani Kosnik Normal.dotmKosnik, Shravani9Microsoft Office Word@e@48-I@6Ճ@?@ABCDEFHIJKLMNPQRSTUVYZ]Root Entry F'\Data *1Table2(WordDocument ERSummaryInformation(GDocumentSummaryInformation8OMsoDataStore''FTOSTGDYPVPA==2''Item  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q