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Fill and Sign the Self Insurer Report of Losses Non Experience Rating Period Oregon Form

Fill and Sign the Self Insurer Report of Losses Non Experience Rating Period Oregon Form

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Workers’ Compensation Division Self-Insured Employer Report of Losses Non-Experience Rating Period Page 1 of       Period covered:       to       Valuation date: Jan. 1,       Self-insured employer name:       In accordance with OAR 436-050, all self-insured employers are required to submit claims loss data to the department for calculation of security deposit. The following information must be submitted by March 1: All claims with dates of injury before the experience rating period that have outstanding reserves as of Jan. 1 must be reported. Attach the required PTD/Fatal Claim Reserve Worksheets. See instructions relating to the submission of these worksheets. Worker’s name Date of injury Claim no. Total paid (a) Outstanding reserves (b) Total incurred losses (a+b) CAT, SIR, WDP, PTD, F, 3 rd , 2 nd injury                               $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00       Totals, this page: $0.00 $0.00 $0.00       Totals from Page 2: $0.00 $0.00 $0.00       Totals from additional pages:             $0.00       Totals for above year: # of claims       $0.00 $0.00 $0.00       (Include total number of claims from attached pages) Ref: Bulletin 209 440-2810 (1/13/DCBS/WCD/WEB) 2810 Self-Insured Employer Report of Losses, Non-Experience Rating Period Page 2 of       Worker’s name Date of injury Claim no. Total paid (a) Outstanding reserves (b) Total incurred losses (a+b) CAT, SIR, WDP, PTD, F, 3 rd , 2 nd injury                               $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00                                     $0.00       Totals (transfer to Page 1): $0.00 $0.00 $0.00       440-2810 (1/13/DCBS/WCD/WEB)

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