Reopened Claims Program Reimbursement Request {1966}

Reopened Claims Program Reimbursement Request Quarter: Year: Self-Insured Employer Insurance Company To: Department of Consumer & Business Services Mail reimbursement to: Workers Compensation Division, Compliance Section In-Office Audit & Certifications Unit Insurance company 350 Winter St. NE, PO Box 14480, Salem, OR 97309-0405 or self-insured employer (and TPA I certify that the payments reported have been made in the amounts indicated, pursuant to if applicable) name ORS 656.278 and ORS 656.625, and have not been previously requested. and address: Reimbursement is requested in the amount of: $ City State ZIP 0.00 Signed: X Date: Type name, title, and phone: ( ) - 1. Claim number 2. Workers names 3. DOI or date 4. Weekly 5. Days 6. Marital/ 7. Temporary 8. TTD/TPD 9. Permanent 10. Total of 1st disability period dollar payments (alpha order) wage off dependency disability disability if last, first status amount dollar occ. disease amount WCD From Ins. Through $0.00 WCD From Ins. Through $0.00 WCD From Ins. Through $0.00 WCD From Ins. Through $0.00 WCD From Ins. Through $0.00 WCD From Ins. Through $0.00 WCD From Ins. Through $0.00 WCD From Ins. Through $0.00 WCD From Ins. Through $0.00 440-1966 (9/03/DCBS/WCD/WEB)