Oregon > Workers Comp > Request For WCD File Information
Request For Workers Compensation Division Claim File Information 3088 - Oregon
| Request For Workers Compensation Division Claim File Information Form. This is a Oregon form and can be used in Request For WCD File Information Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Request for Workers' Compensation Division Claim File Information Workers' Compensation Division Requester information (ship to address) Requester's name: Firm (company) name: Mailing address: City: Phone no.: ( ) Whom do you represent? claimant1 Reason for requesting file information: Claimant information (subject of request) Name: Date of injury: Insurer name: Records request2 Entire file3 Certified Reconsideration Record for Reconsideration Order, dated:4 Hearing date, if known: Certified record for Director's Classification Review Order, dated:4 All records since closure, dated:5 Specific documents5 1 If representing the claimant, include a copy of your retainer agreement or a signed release form. 2 Insurers and self-insured employers keep comprehensive files for each workers' compensation claim, and these files often include documents that have never been submitted to the Workers' Compensation Division. 3 Per OAR 436-060-0009(4), "pursuant to ORS 192.502(19) workers' compensation claims records are exempt from public disclosure. Access to workers' compensation claims records will be granted at the sole discretion of the Director in accordance with this rule..." 4 Authority to charge for records is provided by ORS 192.440(3) and OAR 440-05-025. OAR 436-030-0155 requires the department to charge for the record on reconsideration. Division policy is to charge $.02 per page, $20.00 per hour labor, plus mailing costs, prior to delivery. In an effort to speed delivery of the record on reconsideration, we will provide copies along with a bill. If payment is not made promptly, the department will require pre-payment prior to shipment of future records. 5 Be as specific as possible. General requests may result in copying, mailing, and billing charges for records you do not need. The Workers' Compensation Division will not perform blind searches for records not known to exist, per OAR 436-060-0009(3). State: Fax no.: ( insurer/employer Zip + 4: ) Date of birth: WCD no.: Claim no.: Signature of requester: Send record request to: or fax to (503) 947-7806 440-3088 (9/07/DCBS/WCD/WEB) Date: Workers' Compensation Division Attn: Operations Section 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Phone: (503) 947-7810 3088 American LegalNet, Inc. www.FormsWorkflow.com
|
|||||||
