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Form Wk Comp 10-01 - Corrections And Changes Notification Wbf Assessment - State Of Oregon

Workers’ Comp. Use Only

CORRECTIONS AND CHANGES NOTIFICATION

Date Received

WBF ASSESSMENT

Business Name:

Business Identification Number (BIN)

Workers’ Compensation Insurance Provider

Policy Number

Instructions:

Note: Submitting this notice to the Workers’ Compen-

sation Division will affect only your Workers’ Benefit

Use this Corrections and Changes Notification to inform

Fund assessment account for purposes of reporting. It

the Workers’ Compensation Division:

will not affect your workers’ compensation insurance

•

Of any preprinted information on your Form OQ-WBF

coverage or claims liability. You need to contact your

that is incorrect, or

insurance provider to notify them of the changes.

•

Of any corrections or changes to your Workers’ Com-

pensation Benefit Fund assessment account, or

•

If you no longer are liable for reporting Workers’ Benefit

The preprinted information on Form OQ-WBF is sup-

Fund assessment and wish to close your account.

plied by your insurance provider. Check with your

Do not use this form for changes in partnership, corpor-

insurance company to see if they will accept a copy

ate status or make-up, or changes in the number of per-

of this form as notification to them of any changes or

sonal elections taken.

corrections to your insurance policy.

CORRECTIONS

(enter corrected information)

BIN

Business Name

Mailing Address:

Federal ID No. (EIN)

City

State

ZIP Code

Phone Number

(

)

CHANGES IN STATUS

(check and complete all that apply)

Closed business — Effective date of closure*:

No longer have Oregon employees — Date of final payroll*:

I choose to maintain workers’ compensation insurance coverage, even though I no longer have

employees in Oregon, and I have not chosen by personal election to provide coverage for myself.

(You will be required to confirm this information on an annual basis.)

* If you have already requested cancellation of your workers’

compensation insurance policy, enter date of end of coverage:

Please attach a copy of your cancellation request or the cancellation notice provided by your insurer, if

available.

Now using leased employees only — Date you started using exclusively leased employees:

Name of leasing company:

Other: (Please attach explanation)

I understand that I am required to report and pay the Workers’ Benefit Fund

Mail completed report to:

assessment at any time that I carry workers’ compensation insurance

WC Assessments Unit

coverage for myself or for any of my workers in Oregon.

DCBS, Business Administration Division

350 Winter Street NE, Rm 300

Salem OR 97301-3878

Signature

Date

WK COMP 10-01

Form Wk Comp 10-01 - Corrections And Changes Notification Wbf Assessment - State Of Oregon

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