Exemption Provision Waiver {4965}

Note: Print this Exemption Provision Waiver on company letterhead. EXEMPTION PROVISION WAIVER (date) Self-Insurance Program Workers' Compenation Division Department of Consumer and Business Services P.O. Box 14480 Salem, OR 97309-0405 RE: WCD no. I, (primary company representative) , on behalf of (certified self-insured employer) , do hereby waive the exemption provision of Oregon Revised Statute (ORS) 192.501(5) and give permission to the Oregon Department of Consumer and Business Services, Workers' Compensation Division to discuss and consider recommendations from: (broker, agent, or consultant) concerning detailed self-insurance certification data, specifically, security deposit amounts and requirements, excess insurance coverage levels, and claim loss risk and exposure. By: Print name: Title: (officer responsible for self-insurance program) Date: 440-4965 (6/13/DCBS/WCD/WEB) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com EXCERPT FROM OREGON REVISED STATUTE CHAPTER 192: Workers' Compensation Division - Public Records Exempt from Disclosure Self-Insured Employer Records 1. Self-insured employer experience rating modifications are confidential unless the party is specifically authorized access, in writing, by the self-insured employer. Statutory Reference: ORS 192.501(5). Basic Manual for Workers' Compensation Employer's Liability Insurance, NCCI Rules and Procedures, Appendix A, IV. 2. Annual reports submitted by self-insured employers and the worksheets used for the calculation of security deposits. Statutory Reference: ORS 192.501(5). 192.501(5) Information consisting of production records, sale or purchase records or catch records, or similar business records of a private concern or enterprise, required by law to be submitted to or inspected by a governmental body to allow it to determine fees or assessments payable or to establish production quotas, and the amounts of such fees or assessments payable or paid, to the extent that such information is in a form which would permit identification of the individual concern or enterprise. This exemption does not include records submitted by long term care facilities as defined in ORS 442.015 to the state for purposes of reimbursement of expenses or determining fees for patient care. Nothing in this subsection shall limit the use which can be made of such information for regulatory purposes or its admissibility in any enforcement proceeding. [emphasis added] Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com