"Request and Agreement for Alternative Service and Waiver of a.a.c. R20-5-158(B)" - Arizona

Request and Agreement for Alternative Service and Waiver of a.a.c. R20-5-158(B) is a legal document that was released by the Industrial Commission of Arizona - a government authority operating within Arizona.

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T
I
C
A
HE
NDUSTRIAL
OMMISSION OF
RIZONA
Request and Agreement for Alternative Service and
Waiver of A.A.C. R20-5-158(B)
(“Party”) (FEIN:
)
(Party Type:
Claimant
Attorney
Law Firm
Carrier/Self Insured
Employer)
hereby
requests
and
agrees
that
the Industrial
Commission
of
Arizona
(the
“Commission”) may serve any and all notices, correspondence, subpoenas, documents,
awards,
decisions,
orders,
or
other
matters
required
by
the
Arizona
Workers’
Compensation
Act
(“Document”
or
“Documents”) upon Party in
the following manner (PARTY TO SELECT ONLY ONE OPTION):
 Option “1”: United States Mail (Party Declines Alternative Service)
If selected, the Commission will serve Documents on Party via United States Mail
(pursuant to Arizona Administrative Code (A.A.C.) R20-5-158(B)(1)) to the following
mailing address:
Name:
Address:
City:
State:
Zip Code:
 Option “2”: Alternative Service Via Electronic Facsimile (E-Fax)
If selected, the Commission will transmit Documents to Party via electronic facsimile (E-
Fax) to the following fax number:
Party agrees that transmission of Documents via E-Fax is legally-proper service and shall
be the equivalent of other legally-permissible methods of service (including United States
mail or personal service). Party specifically waives the requirement that service of
Documents be made pursuant to A.A.C. R20-5-158(B). Party agrees that service made
pursuant to Option “2” of this Request and Agreement will be deemed completed at the
time the Commission transmits a Document to the fax number provided above. Party
understands that the Commission will no longer transmit Documents via other methods of
service, including United States Mail, e-mail, or personal service.
 Option “3”: Alternative Service Via Secure File Transfer Protocol (SFTP)
If selected, the Commission will transmit Documents to Party by uploading Documents to
an SFTP account configured for Party. Party agrees that transmission of Documents via
SFTP is legally-proper service and shall be the equivalent of other legally-permissible
methods of service (including United States mail or personal service). Party specifically
waives the requirement that service of Documents be made pursuant to A.A.C. R20-5-
T
I
C
A
HE
NDUSTRIAL
OMMISSION OF
RIZONA
Request and Agreement for Alternative Service and
Waiver of A.A.C. R20-5-158(B)
(“Party”) (FEIN:
)
(Party Type:
Claimant
Attorney
Law Firm
Carrier/Self Insured
Employer)
hereby
requests
and
agrees
that
the Industrial
Commission
of
Arizona
(the
“Commission”) may serve any and all notices, correspondence, subpoenas, documents,
awards,
decisions,
orders,
or
other
matters
required
by
the
Arizona
Workers’
Compensation
Act
(“Document”
or
“Documents”) upon Party in
the following manner (PARTY TO SELECT ONLY ONE OPTION):
 Option “1”: United States Mail (Party Declines Alternative Service)
If selected, the Commission will serve Documents on Party via United States Mail
(pursuant to Arizona Administrative Code (A.A.C.) R20-5-158(B)(1)) to the following
mailing address:
Name:
Address:
City:
State:
Zip Code:
 Option “2”: Alternative Service Via Electronic Facsimile (E-Fax)
If selected, the Commission will transmit Documents to Party via electronic facsimile (E-
Fax) to the following fax number:
Party agrees that transmission of Documents via E-Fax is legally-proper service and shall
be the equivalent of other legally-permissible methods of service (including United States
mail or personal service). Party specifically waives the requirement that service of
Documents be made pursuant to A.A.C. R20-5-158(B). Party agrees that service made
pursuant to Option “2” of this Request and Agreement will be deemed completed at the
time the Commission transmits a Document to the fax number provided above. Party
understands that the Commission will no longer transmit Documents via other methods of
service, including United States Mail, e-mail, or personal service.
 Option “3”: Alternative Service Via Secure File Transfer Protocol (SFTP)
If selected, the Commission will transmit Documents to Party by uploading Documents to
an SFTP account configured for Party. Party agrees that transmission of Documents via
SFTP is legally-proper service and shall be the equivalent of other legally-permissible
methods of service (including United States mail or personal service). Party specifically
waives the requirement that service of Documents be made pursuant to A.A.C. R20-5-
T
I
C
A
HE
NDUSTRIAL
OMMISSION OF
RIZONA
158(B). Party agrees that service made pursuant to Option “3” of this Request and
Agreement will be deemed completed at the time the Commission successfully uploads a
Document to the Party’s SFTP user account. Party understands that the Commission will
no longer transmit Documents via other methods of service, including United States Mail,
e-mail, or personal service. By selecting Option “3”, Party agrees to comply with all end-
user requirements issued by the Commission pertaining SFTP.
(If Option “3” is selected, the Commission will contact Party to configure an SFTP
account. The Commission will contact the following Party Technical Representative to
discuss end-user requirements and SFTP account configuration:
Representative Name:
Representative Phone:
Representative Email:
NOTHING IN THIS REQUEST AND AGREEMENT AFFECTS THE RIGHT OF
PARTY OR THE COMMISSION TO SERVE PROCESS IN ANY MANNER
PERMITTED BY APPLICABLE LAW.
IF OPTION “2” OR OPTION “3” ARE SELECTED: NOTHING IN THIS REQUEST
AND AGREEMENT AFFECTS THE RIGHT OF PARTY OR THE COMMISSION TO
ASSERT LEGAL DEFENSES OR OBJECTIONS EXCEPT FOR SERVICE-RELATED
OBJECTIONS/DEFENSES THAT WOULD OTHERWISE BE PERMISSIBLE UNDER
A.A.C. R20-5-158(B) OR OTHER APPLICABLE LAW.
NOTHING IN THIS REQUEST AND AGREEMENT AFFECTS THE DUTIES OF
PARTY AND THE COMMISSION TO COMPLY WITH SERVICE REQUIREMENTS
RELATED TO NON-PARTIES TO THIS AGREEMENT.
This Request and Agreement shall be effective on the date the Commission’s new
operational or the date the Request and Agreement is
Claims
System
becomes
submitted, whichever is later.
This Request
and
Agreement
will
remain effective
Request
Agreement
until
Party
completes
and
submits
an
updated
and
for alternative service (either using this form or electronically in Party’s account in
the ICA Community).
T
I
C
A
HE
NDUSTRIAL
OMMISSION OF
RIZONA
By signing below, I certify that I am an authorized representative of Party. I further certify that I am
authorized to sign and submit this Request and Agreement and that all of the representations
included in this Request and Agreement are true, accurate, and complete.
Printed Name
Title
E-Mail Address
Phone
Date
Signature
The Commission requests that Parties submit this form on or before May 3,
2019. Parties may submit this form in the following ways:
In-Person or by U.S. Mail:
Industrial Commission of Arizona
c/o MIS, Julie Hill
800 West Washington Street, Suite 103
Phoenix, Arizona 85007
By E-Mail:
Julie.Hill@azica.gov
Questions regarding the completion of this form may be directed to Julie Hill at
Julie.Hill@azica.gov.
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