Form 150-211-158 - Workers' Benefit Fund Assessment Corrections And Changes Notification Sheet - 2013
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1Workers’ Benefit Fund Assessment
Corrections and Changes Notification
•
*
Use this form to update your Workers’ Benefit Fund assessment account
Business name
Oregon Business Identification Number (BIN)
Corrections
(enter corrected information)
Is this address to be used for forms only?
Yes
No
Business name
BIN
Mailing address
Federal Employer Identification Number (FEIN)
City
State
ZIP code
Telephone number
Changes in Status
(check and complete all that apply)
DCBS use only
1. No longer in business. Effective date of closure: _________________________________________
RC02 __________
2. Still in business, but have no paid employees. Effective date: ____________________________
I maintain workers’ compensation insurance coverage:
RC06 __________
Not for myself and/or corporate officers, but in case I hire employees.
A/L
To cover myself and/or corporate officers exclusively; no employees.
To cover volunteer workers exclusively.
RC06 __________
3. I no longer have workers’ compensation insurance coverage:
I have canceled my workers’ compensation insurance coverage.
RC02 __________
Effective date of cancellation: _______________________________________________________
I will be canceling my workers’ compensation insurance coverage.
RC02 __________
Effective date of cancellation: _______________________________________________________
4. I now use leased employees only. Effective date: _______________________________________
RC05 __________
5. Other. Please explain: _________________________________________________________________
* Contact your insurance carrier to make any changes in name, partnership, corporate status, or changes in the
number of personal elections taken. Check with your insurance company to see if it will accept a copy of this form as
notification of any changes or corrections to your insurance policy.
Note: Submitting this notice to the Workers’ Compensation Division will affect only your Workers’ Benefit Fund assessment
account for purposes of reporting. It will not affect your workers’ compensation insurance coverage or claims liability. You
need to contact your insurance provider to notify it of the changes.
I understand that I am required to report and pay the Workers’
Benefit Fund assessment at any time that the law requires or I
Mail your completed form to:
choose to carry workers’ compensation insurance coverage for
WC Assessments Unit
myself or for any of my paid workers in Oregon.
DCBS/CSD/Financial Services
X
PO Box 14480
Signature
Date
Salem OR 97309-0405
Print name
Telephone number
150-211-158 (Rev. 12-13)
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