Service Companys Notification Of Business {4929}

Service company222s notification of business in Oregon Service company information Service company 222s name: FEIN: Gen eral lines agency license no . : Group name (if applicable): Service company222s workers222 compensation address and contacts in Oregon Physical address: Street address: Mailing address: City: State: ZIP +4: General delivery email address for company: Mailing address (if applicable): Mailing address: City: State: Z IP +4: Oregon office primary contact for workers222 compensation (if applicable): Name: Title: Phone: Email address: Fax: I f you have questions, contact the insurer registration specialis t, Workers222 Compensation Division, 503 - 947 - 7705 . Mail this form to: Workers222 Compen s ation Division Attn: Insurer Registration P.O. Box 14480 Salem, OR 97309 - 0405 Or f ax it to: 503 - 947 - 7725 Or e mail it to: insurerregistration.wcd@ oregon.gov Servi ce company representa t ive completing form: Name: Title: Date: Phone: Fax: Email: For department use WCD no.: Date processed: Date rec222d: Initials: 440 - 4929 ( 2 /1 8 /DCBS/WCD/WEB) 4929 American LegalNet, Inc. www.FormsWorkFlow.com