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This is a Oregon form that can be used for Closure within Workers Comp.
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Insurer name, address, and phone: Notice of Closure: Own Motion Claim Pursuant to ORS 656.278(6) Mailing date: Worker: WCD file no.: Date of injury: Date of Own Motion reopening: Social Security no.: Insurers claim no.: This is to advise you that your Own Motion workers compensation claim is now closed. As your insurer, we have reviewed medical and other information about your accepted condition(s) and have determined the extent of your disability. This closure applies to the most recent reopening(s) of your Own Motion claim pursuant to ORS 656.278. Your claim was reopened for: A.Worsened Condition claim submitted after List worsened condition(s) for previously accepted condition(s) for which expiration of aggravation rights. ORS 656.278(1)(a) claim was reopened: B.Post-Aggravation Rights New or Omitted List post-aggravation rights new/omitted medical conditions for which Medical Condition Claim. ORS 656.278(1)(b) claim was reopened: C. Pre-1966 Injury Claims. ORS 656.278(1)(c) 1. Pre-1966 Medical Services Claim. List medical services for which claim was reopened: 2. Pre-1966 Worsened Condition Claim. List worsened condition(s) for previously accepted condition(s) for which claim was reopened: 3. Pre-1966 Post-Aggravation Rights List post-aggravation rights new/omitted medical conditions for which New/Omitted Medical Condition Claim. claim was reopened: Medically stationary date: In accordance with OAR 438-012-0055, you were entitled to time-loss compensation for the Temporary disability following period(s): compensation paid: $ In accordance with ORS 656.278(1)(b), (2)(d), and as summarized below and calculated on the Permanent disability attached closure worksheet (Form 440-2807), you are provided the following permanent disability compensation paid: $ benefits for your compensable post-aggravation rights new/omitted medical condition(s): NOTICE TO WORKER If you think this claim closure is wrong, you may ask the Workers Compensation Board to review it and decide whether you are entitled to more compensation. If you do not ask for review within 60 days of the date of this notice, you will lose any right you may have to contest this notice unless you can show good cause for delay beyond 60 days. After 180 days, all rights will be lost. You may ask for a th review by writing to the Workers Compensation Board, 2601 25 St., Ste. 150, Salem, Oregon 97302-1282. You may have an attorney of your choice, whose fee will be limited to a percentage of any more compensation you may be awarded. (OAR 438-012-0055) Authorized representative: (Please type name): Distribution (one copy each to): Worker Workers representative (if any) Workers Compensation Division By: X Signature Date Insurer This is an important document. Keep it in a safe place. 2066 440-2066 (9/03/DCBS/WCD/WEB)