Reinstatement Notice {5361}

Worker Leasing Reinstatement Notice (Reinstates terminated Worker Leasing Notice) Internal use only Received date: Approved Rejected This notice must be used to reinstate a terminated Worker Leasing Notice (Form 2465). This notice must be filed with the Oregon Workers222 Compensation Division and its insurer within 30 days after the reinstatement becomes necessary. [OAR 436-180-0110(4)] Please fax this notice to 503-947-7820. For other filing options, call 503-947-7675. If you have already removed the Notice of Compliance postings (Form 1188), you must ensure the client reposts the Notice of Compliance poster in a visible manner sufficient to inform workers about the coverage. (ORS 656.056) EFFECTIVE DATE FOR REINSTATEMENT: (M ust match effective date on the Worker Leasing Notice you wish to reinstate) CLIENT INFORMATION (provide ONLY client information in this section) Business entity legal name: FEIN : (do NOT use SSNs) Assumed business name (dba), if any: Client phone: Client email, if known: WORKER LEASING COMPANY INFORMATION Legal name: dba (if used in Oregon) Oregon leasing license no.: WLC000 FEIN: The worker leasing company named above, by signing this Reinstatement Notice and filing it with the Workers222 Compensation Division, hereby guarantees that it is either a self-insured employer certified under ORS 656.407, or has workers222 compensation insurance in effect to cover workers leased to the client and subject workers of the client. Authorized representative name (please print) Email Phone Signature of authorized representative Date 5361 440 - 5361 ( 8 /18/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com