Worker Leasing License Renewal {5364}

5364 - WORKER LEASING LICENSE APPLICATION – RENEWAL. This form is used by worker leasing companies to renew their full license with the Oregon Workers’ Compensation Division. This form must be submitted by companies before their current license expires to ensure continued authorization to operate in Oregon. A fee of $2,050 is due after approval of the renewal. To avoid processing delays, the application must be submitted at least 90 days before the license expiration date, and any required supplemental information must be provided at least 45 days in advance. The renewal form collects updated applicant and contact information, verifies compliance with tax and safety requirements, and requires disclosure of any new criminal, civil, financial, or administrative actions involving the company or its controlling persons. It includes affidavits of truthfulness and authorization for information release. Each controlling person associated with the company must also complete a section of the form and may need to submit a Disclosure Addendum if any new reportable issues have occurred since the last license approval. www.FormsWorkflow.com