Fill and Sign the Worker Leasing Notice Oregon Form

Worker Leasing Notice (Client Proof of Coverage) Internal use only Received date: Approved Rejected The worker leasing company [also known as a Professional Employer Organization (PEO)] must file the Worker Leasing Notice (Form 2465) with the Oregon Workers’ Compensation Division and its insurer within 30 days of providing workers’ compensation coverage for an Oregon client. (OAR 436-180-0110). This notice establishes required proof of coverage for your client. [ORS 656.850(5)] (Note: If your client purchases its own coverage, do NOT file this notice.) Please fax this notice to 503-947-7820. For other filing options, call 503-947-7675. A Worker Leasing Notice does not expire. The worker leasing company may terminate its obligation to provide workers’ compensation coverage by filing a Worker Leasing Termination Notice (Form 3271). Liability will end no sooner than 30 days after the Termination Notice is received by the division, unless new coverage is filed for the client. EFFECTIVE DATE OF OREGON CLIENT COVERAGE:       CLIENT INFORMATION (provide ONLY client information in this section) Business entity legal name:       FEIN:       (do NOT use SSNs) Assumed business name (dba), if any:       Client phone:       Client email, if known:       Oregon location address:       or Home-based employees only       Client mailing address, if different:             Number of client’s covered employees in Oregon:       Type of ownership: Corporation LLC (Limited liability company) Partnership Sole proprietorship Nonprofit Other (specify):       Primary business type (example: retail):       NAICS (industry) code:       Primary NCCI (governing class) code:      COMPLIANCE POSTERS The division provides a Notice of Compliance poster (Form 1188) to the worker leasing company. The worker leasing company is responsible to provide a copy to clients for all client worksites when the worker leasing company provides workers’ compensation coverage. The worker leasing company may provide notices to clients electronically for print out and posting. The worker leasing company must ensure notices are removed from client worksites when it no longer carries coverage. (ORS 656.056) This worker leasing company already has current Notice of Compliance posters and will provide them to this client as required. This worker leasing company needs updated posters. Number of posters requested:       WORKER LEASING COMPANY INFORMATION Legal name:       dba       (if used in Oregon) Oregon leasing license no.: WLC000       FEIN:       The worker leasing company named above, by signing this Worker Leasing Notice and filing it with the Workers’ Compensation Division, hereby guarantees that it is either a self-insured employer certified under ORS 656.407, or has workers’ compensation insurance in effect to cover workers leased to the client and subject workers of the client.                   Authorized representative name (please print) Email Phone       Signature of authorized representative Date 440-2465 (8/18/DCBS/WCD/WEB) 2465