Supplemental Disability Election Notification {3530} | Pdf Fpdf Doc Docx | Oregon

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Supplemental Disability Election Notification {3530} | Pdf Fpdf Doc Docx | Oregon

Supplemental Disability Election Notification {3530}

This is a Oregon form that can be used for Insurer And Self Insurer within Workers Comp.

Alternate TextLast updated: 5/11/2006

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Description

SUPPLEMENTAL DISABILITY ELECTION NOTIFICATION elects the assigned processing agent Insurer / self-insured employer name regarding supplemental disability claims for the year . Insurer representative signature Date Insurer representative name (printed): Title: Phone: If you have any questions regarding this form, you may call the Benefit Consultation Unit at (800) 452-0288. Mail or deliver to: Workers Compensation Division Benefit Consultation Unit 350 Winter St. NE P. O. Box 14480 Salem, OR 97309-0405 Or fax to (503) 947-7612 440-3530 (1/04/DCBS/WCD/WEB)

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