Supplemental Disability Benefits Quarterly Reimbursement Request {3504}

Supplemental Disability Benefits Quarterly Reimbursement Request Self-insured employer Insurance company Quarter: Year To: Department of Consumer & Business Services I certify that payments reported have been made in the amounts indicated and have Workers Compensation Division, Compliance Section not been previously requested. Reimbursement is requested in the amount of: $0.00 In-Office Audit & Certifications Unit Insurance company 350 Winter St. NE, Rm. 27, Salem, OR 97301-3879 From: or self-insured employer (and TPA Signed: X Date: if applicable) name Name and and address: title: (Print or type) Phone: (Print or type) City State ZIP Claim status Workers name, Nondis. or Supplemental disability Supple- Quarter/ WCD WCD file number, Disabling Employers WCD registration no. mental year Employer legal names periods use date of injury, SSN, and and weekly wage disability payment only insurer claim number N D payments made From: Through: Primary employer: *Reg#: Weekly wage: Worker: Scheduled days off: WCD#: Date of injury: Additional employer #1: *Reg#: Pre-injury weekly wage: SSN: Ins#. Additional employer #2 *Reg#: Pre-injury weekly wage: $ Primary employer: *Reg#: Weekly wage: Worker: Scheduled days off: WCD#: Date of injury: Additional employer #1: *Reg#: Pre-injury weekly wage: SSN: Ins#. Additional employer #2 *Reg#: Pre-injury weekly wage: $ *WCD employer registration number: Phone the employer index, (503) 947-7814; fax requests to: (503) 947-7718; e-mail requests to: wcd.employerinfo@state.or.us; look up information on WCDs Web site: www4.cbs.state.or.us/ex/wcd/cov/search/index.cfm. 440-3504 (8/02/DCBS/WCD/WEB)