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Oregon > Workers Comp > Proof Of Coverage - Insurer

Endorsement To Guaranty Contract 3215 - Oregon

Endorsement To Guaranty Contract Form. This is a Oregon form and can be used in Proof Of Coverage - Insurer Workers Comp .
 Fillable pdf Last Modified 5/6/2005
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Endorsement to Guaranty Contract Insert name of insurer and address where policy/coverage information is available: Date of issue: FEIN: Policy no.: BIN or WCD no.: Employers current legal name: If the employers legal name has changed, enter former legal name: Effective date of change: The following partners in the partnership have been admitted (added) or disassociated (deleted): Added or Deleted Added or Deleted The principal mailing address has changed to: The principal place of business address has changed to: The following assumed business names have been: Added or Deleted Added or Deleted Added or Deleted Non-subject worker election of coverage: Yes No Other change(s): Insurer representative signature: Date: Contact name and phone: ( ) 440-3215 (3/04/DCBS/WCD/WEB)
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