Oregon > Workers Comp > Worker Leasing Companies
Application For Worker Leasing Company License 2466 - Oregon
| Application For Worker Leasing Company License Form. This is a Oregon form and can be used in Worker Leasing Companies Workers Comp . |
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Workers' Compensation Division Application for Oregon Worker Leasing License Please refer to Oregon Administrative Rules (OAR) 436-050-0005 and 436-050-0400 through 436-050-0480 Send application to: Workers' Compensation Division Worker Leasing Program 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Telephone: (503) 947-7544 Fax: (503) 947-7718 E-mail: wcd.employerinfo@state.or.us Application Fee: Upon application approval and prior to a license being issued, an application fee of $2,050 will be due. The license fee is for a two-year period. The Workers' Compensation Division will notify the applicant when payment of the required fee is appropriate. Note: If using online form, use computer mouse to navigate through form. Use Web toolbar arrow to return to form after clicking a link. SECTION 1(OAR 436-050-0440(2)) The name of the applicant is the legal name of the "person" seeking a license as an Oregon "worker leasing company"(see OAR 436-0500005(18) and (26) for definitions). 1. 2. Name of applicant: Provide the mailing address of "person" applying for license. This address is not confined to an Oregon location. 3. 4. Address: Telephone number: Federal Tax ID: Identify the business type or structure (e.g. Corporation, Limited Liability Corp, Limited Partnership, General Partnership, Proprietorship, or describe any other business structure). Provide the state and date the business was incorporated, organized, or formed. 5. Business type: State: Date of incorporation, organization, or inception: Obtain the Oregon Registry number from Oregon's Secretary of State. Obtain the BIN from Oregon's Department of Revenue. 6. Oregon Business ID number (BIN): Oregon Registry number: Principal place of business in Oregon (Oregon location where records will be kept and maintained as required under OAR 436-050-0450(1).) Street address: City, State, ZIP: Telephone number: Provide the assumed business names registered with Oregon's Secretary of State. See http://www.filinginoregon.com/business/index.htm. 7. 8. Assumed business names: Workers' compensation insurance coverage of "person" seeking licensure. Obtain the workers' compensation policy number from the Oregon authorized insurer providing coverage. The WCD number is assigned after the insurer makes a proof of coverage filing with the State of Oregon. Workers' compensation insurer: Policy number: WCD employer number: 440-2466 (6/07/DCBS/WCD/WEB Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com 9. Authorized representative(s) for the Oregon business. (Every licensed worker leasing company must have at least one authorized representative of the worker leasing company at the Oregon location authorized to respond to inquiries and make records available regarding leasing arrangements and client contacts. See OAR 436-050-0450(2).) Name: Telephone: E-mail: Name: Name: Telephone: Telephone: E-mail: E-mail: 10. Submit letters of verification and good standing from the controlling regulatory agency of those states in which a worker leasing license or certification was previously or is currently held. 11. Submit letters of verification of compliance with tax laws from Oregon Employment Department, Oregon Department of Revenue, and Internal Revenue Service, using Attachments A, B, and C. Click below. http://www.cbs.state.or.us/external/wcd/compliance/for_worker_leasing.html 12. Provide the plan of operation that demonstrates how the worker leasing company will meet the requirements for occupational safety and health under ORS Chapter 654 including but not limited to: worker training in such areas as hazard communication, personal protective equipment (PPE), fall protection, and hazard identification. You can obtain additional information at: http://www.cbs.state.or.us/external/osha/pdf/pds/pd-246.pdf 13. Provide the plan of operation to ensure collection of information necessary to establish each client's experience rating. 14. Provide the plan of operation to ensure timely and accurate filing of notices to the insurer and director when workers' compensation coverage is provided to a client. (See ORS 656.419, 656.850, OAR 436-050-0100, OAR 436-050-0410.) 15. LICENSE APPLICANT "PERSON" The information in this section is directed to the person making application to be licensed as a worker leasing company in Oregon. A "person" means an individual, partnership, corporation, joint venture, limited liability company, association, government agency, sole proprietorship, or other business entity allowed to do business in the State of Oregon. (See 436-050-0005(18)) Provide all information required under OAR 436-050-0440 (2)(n-q) regarding the "person" making application. Add additional pages as necessary to ensure complete information. 440-2466 (6/07/DCBS/WCD/WEB) Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com 16. Affidavit of applicant I, , acting on behalf of , as the applicant, first being duly sworn, say that, to the best of my knowledge, the applicant is qualified in all respects for the worker leasing company license applied for in the Application for Worker Leasing License; that I have answered all of the questions in this application truthfully; that any and all supporting documents submitted with this application are true, correct, and valid; that there have been no material omissions of fact which would have bearing on the department's decision to grant the requested license; and this affidavit is provided by me in the regular course without fraud or misrepresentation. I hereby authorize all persons, institutions, organizations, schools, governmental agencies, employers, references, or any others set forth directly or by reference in this application, to release to the Workers' Compensation Division, Department of Consumer and Business Services, State of Oregon, any files, records, or information of any type reasonably required for the division to properly evaluate the applicant's qualifications to be licensed as a worker leasing company in Oregon. Under penalty of perjury, I declare that all information provided in this application and accompanying documents, or information I may yet provide to support this application, is true and correct and discloses all material facts regarding the applicant's background and qualifications for licensing. I understand that furnishing false information or failing to disclose information regarding the applicant's background and qualifications may be grounds for refusing to issue a license
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