Insert name, address and phone number of insurer Insurer Notice of Closure Summary WCD File No. Worker (legal name) First MI Last Date of injury (Mo.-Day-Yr.) Address SSN City State ZIP Insurers claim # Employer (legal name), address, city, state, ZIP Date claim statutorily qualifies for closure Attending physician Workers attorney This copy is for your information only. No action is required if the information is correct. Immediately Notice to report any incorrect information to your insurer and to the Oregon Workers Compensation Division, worker: (503) 947-7585, (800) 452-0288, or TTY only: (503) 947-7993. 1. Reason for filing this form (Attach the Notice of Closure, Worksheet, and Updated Notice of Acceptance at Closure as applicable.) (A) Notice of Closure Yes Is the claim being closed after reopening for an accepted new condition? See ORS 656.262(7)(c). No (J) Correct Notice of Closure dated Provide the mailing date printed on the (prior) Notice of Closure being corrected or rescinded. (U) Rescind Notice of Closure dated (W) Request for Preferred Worker eligibility review pursuant to OAR 436-110-0240 2. Claim information since date of injury Time- Total weeks and/or workdays of TTD paid since DOI. Total $ TTD paid since DOI. loss: Total weeks and/or workdays of TPD paid since DOI. Total $ TPD paid since DOI. Check here if you are aware of an overpayment of time-loss benefits. Medical $ Total medical costs paid (including charges received but not yet paid at time of this filing) 3. Preferred Worker and vocational information (At the time of claim closure) Accurate information is necessary to determine the workers eligibility for Preferred Worker and vocational benefits. Return to work type (Check one.) Release to work type (Check one.) (J) Job at injury (same employer) (J) Job at injury without restrictions (A) Job at aggravation (same employer) (A) Job at aggravation without restrictions (M) Modified/restricted duty (M) Restricted duty due to compensable conditions (N) New job (Z) Work restrictions NOT due to compensable conditions (X) No job (X) Unable to work at all due to compensable conditions (PTD) (D) Worker is deceased (Do not complete the (Y) No closing medical information received (administrative remainder of Section 3.) closure under OAR 436-030-0034) Employer type (Check one.) Employment status (Check one.) (S) Employer at injury (P) Permanent (A) Employer at aggravation (T) Temporary (N) New employer (X) Not employed (X) Not employed Yes Did the worker refuse appropriate employment with the employer at original injury or employer at aggravation? No Appropriate employment is defined in OAR 436-110. Explanation: DCBS USE ONLY I certify this information is true and correct, and that all dates required are entered and accurate: X Insurer representative signature Date Name and title (please print) Phone/extension 1503 440-1503 (4/03/DCBS/WCD/WEB) <<<<<<<<<********>>>>>>>>>>>>> 2 Form 1503 completion instructions (not all data fields are described): Section/ number Description/explanation Heading: Date claim statutorily qualifies for closure This is the date the claim satisfies the provisions of ORS 656.268(1). 1.A. Is the claim being closed after reopening for an accepted new condition? Yes/No Check yes if the claim was opened pursuant to ORS 656.262(7)(c); See OAR 436-060-0010(15) and (16). 1.W. Request for Preferred Worker eligibility review pursuant to OAR 436-110-0240 Use this filing option if the conditions of OAR 436-110-0240 (5) (b) + (c) have been met. 2. Time-loss Report TTD and TPD dollars and days actually paid since the date of injury, regardless of prior closures. Do not include any supplemental disability dollars or days paid (pertinent to additional jobs the worker held at the time of injury). Each day or part of a day for which any TTD or TPD is paid counts as one day. Self-insured employers that continue wages in lieu of paying time-loss must report the time-loss that otherwise would have been paid. Report time-loss as a combination of weeks and days, or as days only, or as weeks only. Example: Report either as 4 weeks and 2 days, or as 22 days not both. Check here if you are aware of an overpayment of time-loss benefits. Your checkmark will explain some discrepancies between time-loss paid and authorized and may reduce the number of Form 873 information requests. 3. Preferred Worker and vocational information Job at injury and Job at aggravation refer to the workers job at the time of the injury or aggravation with the same employer. If the worker returns to the same type of work but with a new employer, check New job or Modified/restricted duty (whichever is applicable) under nd Return to work type. If the worker held a 2 job at the time of injury and returns to work at the nd 2 job, the Return to work type is (N) New job and Employment type is (N) New employer. The terms Job at injury, Modified/restricted duty, and Restricted duty refer only to the nd employer-at-injury (where the worker was injured) and NOT to a 2 or additional employer of the worker at the time of injury.