Oregon > Workers Comp > Insurer And Self Insurer
Insurers Report 1502 - Oregon
| Insurers Report Form. This is a Oregon form and can be used in Insurer And Self Insurer Workers Comp . |
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Insert insurer name, third-party administrator name (if applicable), and the mailing address and phone number of the location responsible for processing the claim. INSURER'S REPORT WCD file no.: Worker's legal name: First Address: City: Insured policy holder name as it appears on policy: Covered employer's legal name, if different from above: Covered employer's address: City: State: ZIP: MI Last Date of injury (month-day-year): Social Security no.: State: ZIP: Insurer's claim no.: Policy no.: Status of claim 1 at the time of filing this report. Check one in each column. (A) Accepted (X) Denied (X) Partially denied (D) Disabling (N) Nondisabling (Y) Fatality Date of death: (Y) Occupational disease (N) Injury (O) Original injury (R) Aggravation Mo. Day Yr. (F) First report of claim (Enter date employer first knew of claim - if not reported on attached 801.) Check if claim was previously accepted as nondisabling (Attach acceptance letter; enter date of acceptance.) Reason for filing this form (At least one reason must be checked.) (T) First report of new or omitted condition reopening (Check even if litigation ordered acceptance.) (R) First report of claim for aggravation (Enter date insurer received claim for aggravation.) (V) First report of reopening for voc. training (Enter first date actively engaged in training program.) (L) First report since litigation ordered acceptance (Enter date of order.) (S) Change in acceptance or disability status (Attach copy of letter sent to worker explaining changes.) 2 Complete on all reports. Attach forms 801 and 827 if not previously sent. (P) Notice of partial denial of accepted claim (Attach copy of denial letter.) (C) Correction of wage, SSN, date employer first knew of claim, TTD rate, etc. (Explain below.) (O) Other (Explain below.) (M) MCO enrollment after claim acceptance (Complete MCO section.) 3 4 5 6 7 Weekly TTD rate based on paid-through date. Paid from (this open period): Paid through: $ $ Yes No OR No compensation due. (Skip to #6; explain below). Weekly wage Complete on first reports and wage changes. Explain weekly wage computation if based on information other than that shown on 801, or if 801 is not with first report. If payment was made, provide date of first payment. Salary continued (self-insured employer). No compensation due. (Explain below.) Was first payment of compensation paid timely? Complete only on first reports. OR Was claim accepted or denied timely? Complete on acceptance or denial of claim only. Yes No FOR WCD USE ONLY (Attach copy of acceptance or denial letter.) Is worker enrolled in an MCO? Complete unless enrollment has been previously reported. If "Yes," provide date of enrollment. Yes No MCO no.: Explanations: FOR WCD USE ONLY I certify this information is true and correct and that all dates required are accurate. X Insurer's representative 440-1502 (1/10/DCBS/WCD/WEB) Phone no. of representative Date mailed to WCD (See OAR 436-060-0010 and WCD Bulletin No. 237 for additional instructions.) Contact the Claims Quality Control at 503-947-7810, if you have questions. 1502 American LegalNet, Inc. www.FormsWorkFlow.com General instructions for completing and filing Form 1502 Header: Provide the actual name of the insurance company or self-insured employer responsible for the claim, the third-party administrator (if applicable), and claims processing address and phone number. Claim identifiers: Provide the claimant's name, address, Social Security number (SSN), date of injury, and claim number. The SSN is required under OAR 436-060. Insured policy holder: Provide name of insured entity that purchased the coverage as it appears on the insurance policy. Covered employer's legal name: Provide the legal name of the employer as it appears on the insurance policy (not doing business as name). Policy number: Provide the policy number as it appears on the insurance policy. Section 1: Status of claim Report the status of the claim at the time of filing the 1502 with the division by checking only one item in each of the four columns. "Original Injury": (a) a claim that has not been closed by a Notice of Closure; or (b) a claim that has been closed by a Notice of Closure, but reopened for a new or omitted medical condition or for vocational assistance only. "Aggravation": (a) the actual worsening of the worker's compensable condition(s) on a claim that has been closed by a Notice of Closure; or (b) reclassification of a non-disabling claim as disabling at least one year after original acceptance. Section 2: Reason for filing this form (Complete on all reports- at least one reason must be checked.) Check at least one reason for filing the 1502. Associated dates must be reported in the spaces provided. The following are the most common reasons for filing the 1502: (F) First report of claim File 1502 within 14 days of the insurer's initial decision to either accept or deny the claim (defined in OAR 436-060-0010(10)). The 1502 should be attached directly behind the 801; attach the 827, if available, behind the 1502. To report a disabling aggravation of a previously nondisabling claim, check reasons "F," "R," and "S." (T) First report of new condition reopening File 1502 within 14 days of reopening a claim made under ORS 656.267. Use Form 1503 (instead of the 1502) to report claims that can be closed within 14 days of the first to occur: acceptance of the new or omitted condition; or the insurer's knowledge that interim temporary disability compensation is due and payable. If the new or omitted condition claim is made after the worker's aggravation rights under ORS 656.273 have expired, file Form 3501 (instead of the 1502); see OAR 438-012-0030(4) and OAR 436-060-0010(13). sent to the worker explaining the change. (P) Notice of partial denial of accepted claim File 1502 within 14 days of the denial of a medical condition, treatment, etc., on an otherwise accepted claim. Attach a copy of the denial letter. (C) Correction of wage, SSN, date employer first knew of claim, TTD rate, etc. File 1502 within 14 days of knowledge that previously reported data is incorrect. Describe the correction in the "Explanations" section. (O) Other Check the "Other" filing reason when the above filing reasons do not apply. Examples of appropriate use of this filing reason: (1) to notify WCD that the claim was reopened in error, as reported on an earlier 1502, or (2) to report an amended denial. Describe the filing reason in the "Explanation
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