Oregon > Workers Comp > Worker Leasing Companies
Endorsement To Worker Leasing Notice 3270 - Oregon
| Endorsement To Worker Leasing Notice Form. This is a Oregon form and can be used in Worker Leasing Companies Workers Comp . |
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Endorsement to Worker Leasing Notice Insert name of leasing company and Oregon address. EIN: BIN or WCD No: Clients current legal name: If the clients legal name has changed, give former legal name: Effective date of change: The following partners in the clients partnership have been admitted (added) or disassociated (deleted): Note: File new worker leasing notice if the clients legal entity has changed. added or deleted added or deleted The clients mailing address has changed to: The clients street address has changed to (must be Oregon address): The following assumed business names have been: added or deleted added or deleted added or deleted Other change(s): X Signature of authorized worker leasing company representative Date Contact name and phone: File this endorsement with the Workers Compensation Division and send a copy to your workers compensation insurance carrier. 440-3270 (04/00/DCBS/WCD/WEB)
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