Claim Move Notice {5042}

Claim Move Notice: Changing locations of processing or storing of claims IMPORTANT: The insurer must notify the Oregon Workers222 Compensation Division at least 10 days before the effective date of a change in claims processing location or service company. See OAR 436-050-0110(4) ( insurers) and OAR 436 - 050 - 0210(4) (self - insured employers) for more details on these requirements. NOTE: If an insurer elects to use a service company, a copy of the agreement between the insurer and the service company must be submitted and approved before using the service company in Oregon . Insurer Information Insurer222s name: FEIN: Group name: NAIC: Current Processor and Location Processor n ame: Phone: Contact person: Title: Mailing address: City: State: ZIP: Contact e mail for insure r claims at this processor: New Processor and Location Processor name: Phone: Contact person: Title: Email: Fax: Street address: Mailing address: City: State: ZIP: Transfer Date Effective date: Claims Involved All claims? Yes No D oes this include closed and denied claims? Yes No If no on either of the above, provide specifics of which claims are being moved. (Example: Is it all claims for an employer within a date range? Only open claims?) A complete list must be provided upon request if further clarification is needed. 440-5042 (2/17/DCBS/WCD/WEB) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com If you have questions, contact insurer registration, Workers222 Compensation Division, at 503 - 947 - 7603 or 503 - 947 - 7705 . Mail this form to: OR Workers222 Compensation 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: ins urerregistration.wcd@oregon.gov Insurer representa t ive completing form: Name: Title: Date: Phone: Fax: E mail: For department use WCD n umber : Old proc ess or number : New processor number : Date received: Initials: Date processed : 440 - 5042 ( 2 / 17 /DCBS/WCD/WEB) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com