Fill and Sign the Oregon Workers Compensation 497323813 Form

Workers’ Compensation Division Request for Workers ’ Compensation Division Claim File Information Requester information Requester’s name:       Company name:       Mailing address:       City:       State:       ZIP:       Phone no.:       Fax no.: 1       Email:       Reason for requesting information: Insurer, self-insured employer, third-party administrator, or their legal representative Worker or worker’s legal representative (include copy of retainer agreement or signed release form) Other governmental agency of this state or the United States Other (describe):       Worker information Name:       Date of birth:       WCD file no.:       Social Security no.: 1       Date of injury:       Insurer name:       Insurer claim no.:       Request type Claim history 1 (a summary of all claims on file with the division for a particular worker) Entire file 2 Certified Reconsideration Record for Reconsideration Order, dated:       Hearing date, if known:       Certified record for Director’s Classification Review Order, dated:       All records since closure, dated: 3       Specific documents 3       1 A Social Security number and fax number are required only for claim history requests. 2 OAR 436-060-0009(4) states, “Under ORS 192.502(20) workers’ compensation claims records are exempt from public disclosure. Access to workers’ compensation claims records will be granted at the sole discretion of the director in accordance with this rule…” 3 The Workers’ Compensation Division will not perform blind searches for records not known to exist, under OAR 436-060-0009(3). BY MY SIGNATURE, I certify that I am eligible to receive workers’ compensation claims information in accordance with OAR 436-060-0009 and that I/my company will use the information only as allowed by this rule and all relevant laws of the State of Oregon and the United States. I understand that use of the information for any other purpose shall result in immediate revocation of access and that I/my company may be subject to civil penalties. (ORS 656.745; ORS 656.990) Signature of requester: Date:       Send record request to: or fax to 503-947-7806 Workers’ Compensation Division 3088Attn: Operations Section 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Phone: 503-947-7810 440-3088 (9/16/DCBS/WCD/WEB)