Information Page For Injured Employee {440-3283}

Insurer222s notification of business in Oregon Insurer information Insurer222s name: FEIN: NAIC no : NCCI no : COA no : Group name: NAIC g roup no.: Insurer222s address and contacts for Oregon Workers222 Compensation Headquarters address: Street address: Mailing address: City: State: ZIP +4: General delivery email address for company: Headquarters primary company contact: Name: Title: Phone: Email address: Fax: Insurer222s Oregon address (if applicable): Street address: Mailing address: City: State: Z IP +4: Oregon office primary contact for workers222 compensation (if applicable): Name: Title: Phone: Email address: Fax: Claims information contact: Claims information phone number to be publi shed on WC D222s coverage look - up we b site: NOTE: Insurers must provide a phone number that will provide information on where claims are processed in Oregon. The number will be displayed on the Workers222 Compensation Division222s (WCD) website. OAR 436-050-0110(1)(c) Claims processing location mailing address for insurers with a single Oregon processing location : Street or P . O . Box: City: State: ZIP +4: Web - based c laims location look - up (optional) 226 Web address: Page 1 of 2 1352 440-1352 (2/18/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Payment and collections contact: NOTE: Insurers must provide a contact for payment of penalties and resolution of collection issues resulting from orders issued by t he director. OAR 436 - 050 - 0110 (1)(c) Name: Title: Phone: Email address: Fax: Street or P . O . Box: City: State: Z IP +4: Policy and proof of coverage contact: NOTE: Insurers must provide a designated person or position within the company who can respond to workers222 compensation policy and proo f - of - coverage filing inquiries. OAR 436 - 050 - 0110 (1)(c) Name: Title: Phone: Email address: Fax: Street or P.O. Box: City: State: ZIP+4: Insurer222s service company in Oregon (if any) Service company name : Physical Oregon address: Mailing address: City: State: Z IP +4: Service company contact in Oregon: Name: Title: Phone: Email address: Fax: 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. OAR 436 - 050 - 0110 (2)(b) IMPORTANT: If the insurer222s place of business, or that of its service company, is changed, the insurer must notify the Workers222 Compensation Division of the new location and mailing address of the place of business at least 30 days before the effective date of the change. OAR 436 - 050 - 0110 (3) If you have questions, contact the insurer registration specialist, Workers222 Compensation Division, 503 - 947 - 7705 . Mail this form to: Workers222 Compen s ation Division Attn: Insurer Registration P.O. Box 14480 Salem, OR 97309 - 0405 Or f ax it to: 503 - 947 - 7725 Or e ma il it to: insurerregistration.wcd@ oregon.gov Insurer representa t ive completing form: Name: Title: Date: Phone: Fax: Email: For department use WCD no.: Date processed: Rates eff: Date rec222d: Initials: COA w /WC: 440 - 1352 ( 2 /1 8 /DCBS/WCD/WEB) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com