Service Company Contact Update {5215}

Service Company Contact Update IMPORTANT: The insurer must notify the Oregon Workers222 Compensation Division at least 30 days before the effective date of a change in contact information. See OAR 436-050-0110 (insurers) and OAR 436-050-0210 (self-insured employers) for more details on contact requirements. Company information Company full name: FEIN: Oregon contact information Headquarters (HQ): Contact person: Phone: Email: Fax: Street address: Mailing address: City: State: ZIP: C laims Processing (CLM): Contact person: Phone: Email: Fax: Street address: Mailing address: City: State: ZIP: If you have questions, contact insurer registration, Workers222 Compensation Division, at 503 - 947 - 7705 . Mail this form t o: 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 Service company representa t ive completing form: Name: Title: Date: Phone: Fax: E mail: For department use WCD number: Date received: Initials: Date processed: 440 - 5215 (6/17/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com