Endorsement To Self Insured Group Application {1869}

Endorsement to Self-Insured Group Application Workers' Compensation Division Note: Complete this form for each employer applying to become a member of a self-insured group. 1. 2. Name of self-insured group: Name of member: Address of member: 3. Type of entity (e.g., proprietorship, partnership, corporation): (A) (B) 4. If a corporation, state of incorporation: Registered in Oregon: Yes No Addresses of Oregon locations under entity's name, to include nature of business by location (attach additional sheets, if necessary): 5. Assumed business names and addresses used in Oregon, to include nature of business by location (attach additional sheets, if necessary): 6. 7. 8. 9. 10. Present experience-rating modification: Total number of employees in Oregon: Estimated annual payroll by class code: Name of current workers' compensation carrier: WCD employer number: Attach the following documents to this report: Current financial statement of the employer applying. Form 440-1866, or other form authorized by the director under 436-050-0270 and 436-0500290; or, if a governmental subdivision, a resolution by the governing body of the member binding it to be liable for the payment of any compensation and moneys due to the director incurred by the member. Statement showing the effect on the net worth of the group. Payroll by class and description and loss information for the past four fiscal or calendar years. Send completed Endorsement and all application materials to: Workers' Compensation Division, Self-Insurance Team, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405, or fax to 503-947-7725 440-1869 (11/12/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com