Oregon > Workers Comp > Insurer And Self Insurer

Supplemental Disability Benefits Quarterly Reimbursement Request 3504 - Oregon

Supplemental Disability Benefits Quarterly Reimbursement Request Form. This is a Oregon form and can be used in Insurer And Self Insurer Workers Comp .
 Fillable pdf Last Modified 4/14/2010
Get this form for FREE as a print-only pdf

Supplemental Disability Benefits Quarterly Reimbursement Request Self-insured employer Insurance company Quarter: Year To: Department of Consumer & Business Services I certify that payments reported have been made in the amounts indicated and have Workers Compensation Division, Compliance Section not been previously requested. Reimbursement is requested in the amount of: $0.00 In-Office Audit & Certifications Unit Insurance company 350 Winter St. NE, Rm. 27, Salem, OR 97301-3879 From: or self-insured employer (and TPA Signed: X Date: if applicable) name Name and and address: title: (Print or type) Phone: (Print or type) City State ZIP Claim status Workers name, Nondis. or Supplemental disability Supple- Quarter/ WCD WCD file number, Disabling Employers WCD registration no. mental year Employer legal names periods use date of injury, SSN, and and weekly wage disability payment only insurer claim number N D payments made From: Through: Primary employer: *Reg#: Weekly wage: Worker: Scheduled days off: WCD#: Date of injury: Additional employer #1: *Reg#: Pre-injury weekly wage: SSN: Ins#. Additional employer #2 *Reg#: Pre-injury weekly wage: $ Primary employer: *Reg#: Weekly wage: Worker: Scheduled days off: WCD#: Date of injury: Additional employer #1: *Reg#: Pre-injury weekly wage: SSN: Ins#. Additional employer #2 *Reg#: Pre-injury weekly wage: $ *WCD employer registration number: Phone the employer index, (503) 947-7814; fax requests to: (503) 947-7718; e-mail requests to: wcd.employerinfo@state.or.us; look up information on WCDs Web site: www4.cbs.state.or.us/ex/wcd/cov/search/index.cfm. 440-3504 (8/02/DCBS/WCD/WEB)
Link/Embed this Document
URL
Embed


Popular Searches

  1. stipulation of discontinuance
  2. Notice and Acknowledgment of Receipt
  3. proof of service of summons
  4. Decree of Dissolution of Marriage
  5. Petition to Expunge
  6. writ of replevin
  7. fee waiver
  8. motion for continuance
  9. Income and Expense Declaration
  10. divorce forms

Bookmark and Share