Fill and Sign the Guaranty Contract Oregon Form

Guaranty Contract Between the insurer and the Department of Consumer and Business Services (Use only for workers’ compensation policy coverage effective before July 1, 2009) Dept. use only 1. Mailing date:       Workers’ Compensation Division 2. Legal name of employer (not assumed business name):       3. Federal tax number (FEIN):       4. Business identification number (BIN):       5. Type of ownership (sole owner, partnership, corporation, etc.):       6. Number of Notices of Compliance needed for posting:    7. Annual average number of employees in Oregon:       8. Primary nature of business in Oregon (Example: Logging, restaurant, barber shop, etc.):       9. Primary NCCI code:       10. Has employer had previous coverage? Yes No 11. If yes, give Oregon WCD employer no.:       12. Employer’s mailing address:       City:       State:       ZIP:       Principal place of business in Oregon 13. Name (assumed business name, if any):       14. Phone:       15. Street address (required):       City:       State:       ZIP:       16. Other assumed business names, if any, in Oregon:       17. Nonsubject worker election of coverage: Yes No 18. The insurer named below, by signing this Guaranty Contract and filing it with the Workers’ Compensation Division, hereby guarantees that it is authorized to write workers’ compensation insurance in Oregon. It agrees to assume, without monetary limit, the liability of the above- named employer during the period that this Guaranty Contract is in effect, for prompt payment of all compensation for compensable injuries that may become due under Oregon workers’ compensation laws to subject workers and their beneficiaries, and for other obligations imposed on the insured employer by the workers’ compensation statutes, except penalties assessed against the employer that are specifically exempted by statute. This Guaranty Contract may be terminated by giving written notice to both the Workers’ Compensation Division and the employer stating that on a date not less than 45 days after the date the notice is mailed to the employer such termination shall be effective. Such termination will in no way limit the liability of the insurer incurred under the Guaranty Contract prior to such termination. If the termination of a guaranty contract is based on nonpayment of premium, the termination is effective not sooner than 10 days after the date the notice is mailed to the employer. 19. Insurance company name and address where Guaranty Contract information is available:       20. Policy number:       21. Effective date (must be before 7/1/09):       22. Contact name and phone:       23. Insurer representative signature 440-821 (5/09/DCBS/WCD/WEB) 1. Mailing date : The date the Guaranty Contract is mailed by regular mail or sent via facsimile to the Workers’ Compensation Division. If the contract is delivered to the division by the insurer or by private courier, write “DELIVERED” in this field. 2. Legal name of employer : A separate Guaranty Contract must be completed for each employing legal entity. The name of the employer should be the legal name and not the assumed business name. State the exact legal name as registered with the Oregon Secretary of State, Corporation Division; if not registered with the Corporation Division, state the legal name as registered with the Oregon Department of Revenue or the Oregon Employment Department. 3. Federal tax number or Federal Employer Identification Number (FEIN) : Identification number assigned to the employer by the Internal Revenue Service. 4. Business identification number (BIN): This number is assigned by the Oregon Department of Revenue and is printed on the employer’s Oregon Tax Coupons (OTCs). 5. Type of ownership : Enter an exact description of the legal entity of the employer (e.g., association, corporation, estate, individual, joint venture, labor union, limited partnership, limited-liability company, limited-liability partnership, partnership, political subdivision, trust, religious organization, or executor). State the ownership as registered with the Oregon Secretary of State, Corporation Division; if not registered with Corporation Division, state the ownership as registered with the Oregon Department of Revenue or the Oregon Employment Department. 6. Number of Notices of Compliance needed for posting : Number should include at least one for each of the employer’s operation locations. 7. Annual average number of employees in Oregon : Enter the number of workers. The number indicated in this block should be as accurate as possible. If seasonal, average the number over a 12-month period. 8. Primary nature of business in Oregon : The nature of business should accurately describe the primary activity of the employer within the state. Examples: nitric acid mfg., boys’ sport shirt mfg., or laboratory instrument repair. 9. Primary NCCI code : Enter that class of work in Oregon in which the greatest payroll occurs. 10. Has employer had previous coverage? : Indicate whether or not the employer has previously acquired Oregon workers’ compensation coverage. 11. If yes, give Oregon WCD employer number : This is a seven-digit number assigned to the employer by the Workers’ Compensation Division. 12. Employer’s mailing address : Enter the mailing address for the principal office of the employer, whether or not it’s in Oregon. 13. Name (assumed business name, if any) : Indicate the assumed business name, if any, used at the employer’s primary place of business in Oregon. 14. Phone : Give the phone number at the employer’s primary place of business in Oregon. 15. Street address : Give the street address of the employer’s primary place of business in Oregon. If the employer has no specific location, so indicate; do not leave blank. 16. Other assumed business names, if any, in Oregon : List all other assumed business names used by the employer in Oregon. 17. Nonsubject worker election of coverage : Indicate coverage of personal election by sole proprietors and members of partnerships, corporate officers, or coverage elected by the employer for any nonsubject worker. 18. Guaranty Contract language: Read this section carefully before signing Guaranty Contract. 19. Insurance company name and address where Guaranty Contract information is available : Enter the complete name of the insurer as it is registered with the Oregon Insurance Division. Identify the specific insurer if within an insurance group. 20. Policy number : Enter the number assigned to the insurance policy by the insurer. 21. Effective date: The date application and fees or premium are received and accepted by an authorized representative of the insurer or a later date, if requested. In either case, the effective date must be before July 1, 2009. For policies effective after July 1, 2009, insurers must file proof of coverage electronically according to OAR 436-160. [renumbered as OAR 436-162, eff. 1/1/11] 22. Contact name and phone: Provide name and phone number of person who can answer questions about this Guaranty Contract. 23. Insurer representative signature: The person signing the Guaranty Contract must be an insurer representative. State of Oregon, Department of Consumer and Business Services 350 Winter Street NE, P.O. Box 14480, Salem, OR 97309-0405 (440-821 p.2)