"Request for Substitute Social Security Number (Ssn) Jurisdiction Assigned Number (Jan)" - Montana

Request for Substitute Social Security Number (Ssn) Jurisdiction Assigned Number (Jan) is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on September 23, 2021;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

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Workers’ Compensation
Claims Assistance Bureau
Data Management Section
Greg Gianforte, Governor
Laurie Esau, Commissioner
Request for Substitute Social Security Number (SSN)
Jurisdiction Assigned Number (JAN)
Montana rejects FROI and SROI submissions with invalid Social Security numbers (SSN). Montana
statute requires SSN’s for workers’ compensation claimants. However, there may be cases when a SSN
is not available. For those instances, Montana staff must be contacted directly to obtain a JAN which
will be used on submitted FROIs and SROIs until the SSN is obtained.
Trading Partners not having a valid Social Security Number for a claimant may have a Jurisdiction
Assigned Number (JAN) assigned by completing the following information and emailing it to Cathy
Haag or Doug Roope at
(catherine.haag@mt.gov,
doug.roope@mt.gov) or fax (406-444-4140). If
you have questions, please call Cathy Haag (406-444-3089) or Doug Roope (406-444-1600).
Carrier Information
Name:
FEIN:
Claimant Information
Last Name:
First Name:
MI:
DOB:
Address:
City:
State:
Zip:
Requestor Information
Name:
Company Name:
Phone Number:
Email Address:
Date of Request:
For ERD office use only
Assigned JAN Number: DLI
Date:
ERD/DMU – Request for Jurisdiction Assigned Number – 9.23.2021
Workers’ Compensation
Claims Assistance Bureau
Data Management Section
Greg Gianforte, Governor
Laurie Esau, Commissioner
Request for Substitute Social Security Number (SSN)
Jurisdiction Assigned Number (JAN)
Montana rejects FROI and SROI submissions with invalid Social Security numbers (SSN). Montana
statute requires SSN’s for workers’ compensation claimants. However, there may be cases when a SSN
is not available. For those instances, Montana staff must be contacted directly to obtain a JAN which
will be used on submitted FROIs and SROIs until the SSN is obtained.
Trading Partners not having a valid Social Security Number for a claimant may have a Jurisdiction
Assigned Number (JAN) assigned by completing the following information and emailing it to Cathy
Haag or Doug Roope at
(catherine.haag@mt.gov,
doug.roope@mt.gov) or fax (406-444-4140). If
you have questions, please call Cathy Haag (406-444-3089) or Doug Roope (406-444-1600).
Carrier Information
Name:
FEIN:
Claimant Information
Last Name:
First Name:
MI:
DOB:
Address:
City:
State:
Zip:
Requestor Information
Name:
Company Name:
Phone Number:
Email Address:
Date of Request:
For ERD office use only
Assigned JAN Number: DLI
Date:
ERD/DMU – Request for Jurisdiction Assigned Number – 9.23.2021