Insurers Report {440-1502}

Insert insurer or self - insured employer name, service company name (if applicable), and the mailing address and phone number of the location responsible for processing the claim. INSURER222S REPORT DO NOT USE THIS FORM FOR OWN MOTIO N CLAIMS 226 USE FORM 3501 WCD file no.: Worker222s legal name: First MI Last Date of injury (month - day - year): Address: Social Security no .: City: State: ZIP: Insurer222s claim no.: Insured policy holder name as it appears on policy : Policy no.: Covered e mployer222s legal name , if different from above : Covered e mployer222s address: City: State: ZIP: 1 Status of claim at the time of filing this report. Check one in each column. (A) Accepted (X) Denied (X) Partially denied (D) Disabling (N) Nondisabling (Y) Fatality (Y) Occupational disease (N) Injury (O) Original injury (R) Aggravation Date of death: Mo. 226 Day 226 Yr. 2 Reason for filing this form (At least one reason must be checked.) Complete on all reports. Attach forms 801 and 827 if not previously sent. (F) First report of claim (Enter date employer first knew of claim - if not reported on attached 801.) Check if claim was previously accepted as nondisabling (Attach acceptance letter; enter date of a cceptance.) (T) First rep ort of new or omitted condition reopening (Check even if litigation ordered acceptance.) (R) First report of claim for aggravation (Enter date insurer received claim for aggravation.) ( V) First report of reopening for v oc. training (Enter first date actively engaged in training program.) (L) First report since a litigation order or stipulated agreement resulted in a change in the acceptanc e or disability status (Enter date of order.) (S) Change in acceptance or disability status (Attach copy of letter sent to worker explaining changes.) (P) Notice of partial denial of a ccepted claim (Attach copy of denial letter.) (C) Correction of wage, SSN, date employer first knew of claim, TTD rate, etc. (Explain below.) (O) Other (Explain below.) (M) MCO enrollment af ter claim acceptance (Complete MCO section.) 3 Weekly TTD rate based on paid-through date. $ Paid from (this open period): Paid through: No compensation due. (Skip to #6; explain below) . OR 4 Weekly wage Complete on first reports and wage changes. $ Explain weekly wage computation if based on information other than that shown on 801, or if 801 is not with first report. 5 Was first payment of compensation paid timely? Complete only on first r eports. Yes No If payment was made, provide date of first payment. Salary continued (self-insured employer). No compensation due. (Explain below.) OR 6 Was claim accepted or denied timely? Complete on acceptance or denial of claim only. Yes No (Attach copy of acceptance or denial letter.) FOR WCD USE ONLY 7 I s worker enrolled in an MCO? Complete unless enrollment has been previously reported. Yes No If 223Yes,224 provide date of enrollment. MCO no.: Explanations: FOR WCD USE ONLY I certify this information is true and correct and that all dates required are accurate. X Insurer222s representative P hone no. of representative Date mailed to WCD 440 - 1502 ( 9 /18 /DCBS/WCD/WEB) (See OAR 436 - 060 - 001 1 and WCD Bulletin No. 237 for additional instructions , and OAR 438-012-0001(4), ORS 656.278, and Bulletin 195 for Own Motion claims.) Contact the Claims Qual ity Control at 503 - 947 - 7810, if you have questions. 1502 American LegalNet, Inc. www.FormsWorkFlow.com General instructions for completing and filing Form 1502 Header: Provide the actual name of the insurance company or self-insured employer responsible for the claim, the service company (if applicable), and claims processing address and phone number. Claim identifiers: Provide the claimant222s name, address, Social Security number (SSN), date of injury, and claim number. The SSN is required under OAR 436-060. Insured policy holder: Provide name of insured entity that purchased the coverage as it appears on the insurance policy. Covered employer222s legal name: Provide the legal name of the employer as it appears on the insurance policy (not doing business as name). Policy number: Provide the policy number as it appears on the insurance policy. Section 1: Status of claim Report the status of the claim at the time of filing Form 1502 with the division by checking only one item in each of the four columns. 223Original Injury224: (a) a claim that has not been closed by a Notice of Closure; or (b) a claim that has been closed by a Notice of Closure, but reopened for a new or omitted medical condition or for vocational assistance only. 223Aggravation224: (a) the actual worsening of the worker's compensable condition(s) on a claim that has been closed by a Notice of Closure; or (b) reclassification of a non-disabling claim as disabling at least one year after original acceptance. Section 2: Reason for filing this form (Complete on all reports. At least one reason must be checked.) Check at least one reason for filing Form 1502. Associated dates must be reported in the spaces provided. The following are the most common reasons for filing Form 1502: (F) First report of claim File Form 1502 within 14 days of the insurer222s initial decision to either accept or deny the claim. Form 1502 should be attached directly behind Form 801; and attach Form 827, if available, behind Form 1502. To report a disabling aggravation of a previously nondisabling claim, check reasons "F," "R," and "S." (T) First report of new or omitted condition reopening File Form 1502 within 14 days of reopening a claim made under ORS 656.267. Use Form 1503 (instead of Form 1502) to report new condition claims that can be closed within 14 days of the first to occur: acceptance of the new condition, or the insurer222s knowledge that interim temporary disability compensation is due and payable. If the new or omitted condition claim is made after the worker222s aggravation rights under ORS 656.273 have expired, file Form 3501 (instead of Form 1502); see OAR 438-012-0030(4) and OAR 436-060-0011(8). (R) First report of claim for aggravation File Form 1502 within 14 days of the insurer222s decision to reopen or deny the claim under ORS 656.273. Report the date the insurer first received the claim for aggravation, i.e., the date of receipt of Form 827 signed by the worker or the worker222s attorney and the worker222s attending physician indicating an aggravation claim. (V) First report of reopening for vocational training File Form 1502 within 14 days of reopening the claim for vocational training services under OAR 436-120. Report the first date the worker is actively engaged in training. (L) First report since a litigation order or stipulated agreement resulted in a change in the acceptance or disability status File Form 1502 within 14 days of the date of a litigation order or stipulated agreement that changes the acceptance or disability status of the claim. Report the date the litigation order was signed by the approving authority or, in the case of a stipulation, the date an order approving the stipulation was signed by the approving authority. (S) Change in acceptance or disability status File Form 1502 within 14 days of the status change. Describe the change in the "Explanations" section. Attach a copy of the notice sent to the worker explaining the change. (P) Notice of partial denial of accepted claim File Form 1502 within 14 days of a denial that occurs after the initial Form 1502 has been filed on an otherwise accepted claim. Attach a copy of the denial letter. (C) Correction of wage, SSN, date employer first knew of claim, TTD rate, etc. File Form 1502 within 14 days of knowledge that previously reported data is incorrect. Describe the correction in the "Explanations" section. (O) Other Check the 223Other224 filing reason when the above filing reasons do not apply. Examples of appropriate use of this filing reason: (1) to notify WCD that the claim was reopened in error, as reported on an earlier submitted Form 1502; or (2) to report an amended denial. Describe the filing reason in the "Explanations" section. (M) MCO enrollment after claim acceptance File Form 1502 within 14 days of enrollment unless enro