Oregon > Workers Comp > Worker Leasing Companies
Termination Of Workers Compensation Coverage To Client Of Worker Leasing Company 3271 - Oregon
| Termination Of Workers Compensation Coverage To Client Of Worker Leasing Company Form. This is a Oregon form and can be used in Worker Leasing Companies Workers Comp . |
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Termination of Workers Compensation Coverage to Client of Worker Leasing Company Insert name of worker leasing company and Oregon address: This notice is to inform you that we are terminating our obligation to provide workers compensation coverage for workers provided to you and other subject workers you employ. Copies of this termination notice have been sent to our workers compensation insurer and to the State of Oregon, Department of Consumer and Business Services, Workers Compensation Division. You must remove from your premises (i.e. no longer post) all State of Oregon Notices of Compliance (Form 440-1188) that show us as the covered employer. Clients legal name and mailing address: EIN: BIN or WCD No: Termination effective at 12:01AM: Date X Signature of authorized worker leasing company representative Date Contact name and phone: 440-3271 (12/99/DCBS/WCD/WEB)
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