Oregon > Workers Comp > Worker Leasing Companies
Worker Leasing Notice To Department Of Consumer And Business Services 2465 - Oregon
| Worker Leasing Notice To Department Of Consumer And Business Services Form. This is a Oregon form and can be used in Worker Leasing Companies Workers Comp . |
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Dept. use only Worker Leasing Notice Emp. #: to the Department of Consumer & Business Services Ins. #: To be filed by the leasing company whenever it provides workers to a client pursuant to ORS 656.850. 1. Mailing date: Client information 2. Legal name of client (not assumed business name): 3. Employer identification no. (EIN): 4. Business identification number (BIN): 5. Type of ownership (sole owner, partnership, corp., etc.): 6. Annual average number of employees in Oregon: 7. Primary NCCI code: 8. Primary nature of business in Oregon 9. Has client had previous coverage? (Examples: plywood fabrication, auto repair shop, etc.): Yes No 10. If Yes, give Oregon WCD employer no: 11. Assumed business name(s), if any: Phone: 12. Client mailing address: City: State: ZIP: 13. Clients Oregon street address (required): City: State: ZIP: 14. Employer Identification No. (EIN): Worker leasing company information 15. Worker leasing company name: 16. BIN or WCD emp. no.: 17. Workers compensation insurer name: 18. WCD license number: 19. Worker leasing company Oregon mailing address: City: State: ZIP: 20. The worker leasing company named above, by signing this Worker Leasing Notice and filing it with the Workers Compensation Division (WCD), hereby guarantees that: A. It has been licensed by the Department of Consumer & Business Services (DCBS) to perform services as a worker leasing company in the State of Oregon. B. It is either a self-insured employer certified pursuant to ORS 656.407 or has workers compensation insurance in effect to cover the liability of the above-named client, during the period this Worker Leasing Notice is in effect, for prompt payment of all compensation for injuries that may become due under the Oregon Workers Compensation Laws to workers being leased by the worker leasing company and to subject workers of the client. C. A worker leasing company may terminate its obligation to provide workers compensation coverage by giving to the client, WCD, and the leasing companys insurer, written notice of termination. Liability shall end not less than 30 days after the notice is received by WCD. 21. Effective date of worker lease contract: 22. Contact name and phone: 23. Number of Notices of Compliance needed for posting: 24. (Notify client of posting requirement.) X Signature of authorized worker leasing company representative 440-2465 (04/00/DCBS/WCD/WEB) <<<<<<<<<********>>>>>>>>>>>>> 2 1. Mailing date: The date the Worker Leasing Notice is mailed by regular mail to the Workers Compensation Division. If the notice is delivered by private courier, write Delivered in this field. 2. Legal name of client: State legal name as registered with the Oregon Secretary of State, Corporation Division; if not registered with Corporation Division, state ownership as registered with the Oregon Department of Revenue and/or the Oregon Employment Department. Do not provide an assumed business name. 3. Employer identification number (EIN): Number assigned to the client by the Internal Revenue Service. (Same as Federal Tax Identification Number) 4. Business identification number: This number is assigned by the Oregon Department of Revenue and is printed on the employers Oregon Tax Coupons (OTCs). 5. Type of ownership: Enter an exact description of the legal entity of the client, e.g.: sole proprietorship, partnership, joint venture, association, receivership, administrator, executor, trust, corporation, limited liability company or limited liability partnership. State ownership as registered with the Oregon Secretary of State, Corporation Division; if not registered with Corporation Division, state ownership as registered with the Oregon Department of Revenue and/or the Oregon Employment Department. A separate Worker Leasing Notice must be completed for each client legal entity. 6. Annual average number of employees in Oregon: Enter the number of workers. The number indicated in this block should be as accurate as possible. If seasonal, average the number over a 12-month period. 7. Primary National Council on Compensation Insurance (NCCI) code: Enter that class of work in Oregon in which the greatest payroll occurs. 8. Primary nature of business in Oregon: The nature of business should accurately describe the primary activity of the client within the state. 9. Has client had previous coverage: Indicate whether or not the client has previously acquired Oregon workers compensation coverage. 10. If Yes, give Oregon WCD employer number: This is a seven-digit number previously assigned to the client by the Workers Compensation Division. 11. Assumed business name(s), if any: Indicate the assumed business name(s), if any, used at the clients primary place of business in Oregon. Provide a phone number for the clients primary place of business in Oregon. 12. Client mailing address: Enter the mailing address for the principal office of the client, whether or not it is in the state of Oregon. 13. Clients Oregon street address: Give the street address of the clients primary place of business in Oregon. 14. Employer identification number (EIN): Number assigned to the worker leasing company by the IRS. (Same as Federal Tax Identification Number) 15. Worker leasing company name: State legal name as registered with the Oregon Secretary of State, Corporation Division; if not registered with Corporation Division, state ownership as registered with the Oregon Department of Revenue and/or the Oregon Employment Department. Do not provide an assumed business name. 16. Business identification number (BIN) or WCD employer number: The BIN is assigned by the Oregon Department of Revenue and is printed on the employers Oregon Tax Coupons (OTCs). The WCD employer number is a seven-digit number assigned to the leasing company by the Workers Compensation Division. 17. Workers compensation insurer name: Enter carrier name. 18. License number: Enter the number assigned to the worker leasing company by the Workers Compensation Division. 19. Worker leasing company Oregon mailing address: Enter address. 20. Agreement language: Read this section carefully before signing the Worker Leasing Notice. 21. Effective date of worker lease contract: Enter the date the worker leasing company/client contract is effective. 22. Contact name and phone: Provide name and phone number of person who can answer questions about this Worker Leasing Notice. 23. Number of Notices of Compliance needed for posting: Notices are mailed to the leasing co
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