Request For Reimbursement From Retroactive Program {3285} | | Oregon

 Oregon   Workers Comp   Insurer And Self Insurer 
Request For Reimbursement From Retroactive Program {3285} | | Oregon

Last updated: 10/20/2006

Request For Reimbursement From Retroactive Program {3285}

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Description

REQUEST FOR REIMBURSEMENT FROM THE RETROACTIVE PROGRAM To: Department of Consumer & Business Services Workers' Compensation Division Compliance Section 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 B. C. D. For the period through FATAL BENEFITS A. E. F. SUBTOTAL: PERMANENT TOTAL DISABILITY A. B. C. D. E. $0.00 F. G. H. SUBTOTAL: TEMPORARY TOTAL DISABILITY A. B. C. D. E. F. G. SUBTOTAL: TOTAL THIS QUARTER: I certify that the payments reported have been made in the amounts indicated and have not been previously reimbursed. . Reimbursement is requested in the amount of Mail reimbursement to insurer: TPA: Address: Signed: Title: 440-3285 (9/06/DCBS/WCD/WEB) $0.00 H. $0.00 $0.00 Print or type name: Telephone No: ( ) American LegalNet, Inc. www.FormsWorkflow.com

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