Get free non-fillable PDF
This is a Oregon form that can be used for Self Insured Employer within Workers Comp.
Last updated: 12/28/2016Add to favorites $ 13.99
Download Now$ 13.99
Back to search
CLAIMS RESERVED IN EXCESS OF SELF-INSURED RETENTION valued as of 1/1/ Self-Insured: Future liability Have claim covered by Self-insured payments excess exceeded retention insurance SIR? (SIR) Amount Amount Yes or no (year) Worker's name Last name, first name Date of injury Excess insurer name/ policy number Is self-insured receiving reimbursement?* Yes* or no Excess insurer notified?** Yes** or no * If yes, also please provide percentage of claim costs being reimbursed. ** If yes, please provide proof of proper reporting to the excess carrier as requested in Bulletin 209. FAILURE TO SUBMIT THIS FORM MAY RESULT IN THE AMOUNT OF THE SECURITY DEPOSIT BEING DETERMINED WITHOUT REGARD TO EXCESS INSURANCE REIMBURSEMENT. If you have questions about this form, contact Jody Howatt at 503-947-7699 or Angie Sousa at 503-947-7716. Prepared by: Phone number: Return form to: Department of Consumer and Business Services Workers' Compensation Division/Performance Section P.O. Box 14480 Salem, OR 97309-0405 440-2937 (1/16/DCBS/WCD/WEB) 2937 American LegalNet, Inc. www.FormsWorkFlow.com