Fill and Sign the Oregon Disability Benefits Form

Supplemental Disability Benefits Quarterly Reimbursement Request Self-insured employer Insurance company Quarter: Year To: Department of Consumer and Business Services Workers’ Compensation Division, Performance Section Audit and Reimbursement Team 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405I certify that payments reported have been made in the amounts indicated and have not been previously requested. Reimbursement is requested in the amount of: $0.00 From: Insurance company or self-insured employer (and TPA if applicable) name and address:       Signed: X Date:                   Name and title:       (Print or type)       Phone:       (Print or type) City State ZIP Worker’s name, WCD file number, date of injury, SSN, and insurer claim number Claim status Employer legal names Employer’s WCD registration no. or policy no.* Weekly wage Supplemental disability periods Supple- mental disability payments Quarter/ year payment made WCD use onlyNondis. or Disabling N D From: Through: Worker:       WCD#:       Date of injury:       SSN:       Ins. #:       Primary employer:             Weekly wage:                   $                   Scheduled days off:                               Additional employer #1:             Pre-injury weekly wage:                               Additional employer #2             Pre-injury weekly wage:                               Worker:       WCD#:       Date of injury:       SSN:       Ins. #:       Primary employer:             Weekly wage:                   $                   Scheduled days off:                               Additional employer #1:             Pre-injury weekly wage:                               Additional employer #2             Pre-injury weekly wage:                               *WCD employer registration or policy number: Call the employer index, 503-947-7814; fax requests to 503-947-7718; email requests to wcd.employerinfo@oregon.gov; look up information on WCD’s website: http://www4.cbs.state.or.us/ex/wcd/cov/. 440-3504 (11/09/DCBS/WCD/WEB)