Workers' Benefit Fund Assessment Corrections and Changes Notification · Use this form to update your Workers' Benefit Fund assessment account* Business name Oregon Business Identification Number (BIN) Corrections (enter corrected information) Is this address to be used for forms only? Business name Mailing address City State ZIP code Yes No BIN Federal Employer Identification Number (FEIN) Telephone number Changes in Status (check and complete all that apply) DCBS use only 1. No longer in business. Effective date of closure: _________________________________________ 2. Still in business, but have no paid employees. Effective date: ____________________________ I maintain workers' compensation insurance coverage: Not for myself and/or corporate officers, but in case I hire employees. To cover myself and/or corporate officers exclusively; no employees. To cover volunteer workers exclusively. 3. I no longer have workers' compensation insurance coverage: I have canceled my workers' compensation insurance coverage. Effective date of cancellation: _______________________________________________________ I will be canceling my workers' compensation insurance coverage. Effective date of cancellation: _______________________________________________________ 4. I now use leased employees only. Effective date: _______________________________________ 5. Other. Please explain: _________________________________________________________________ RC02 __________ RC06 __________ A/L RC06 __________ RC02 __________ RC02 __________ RC05 __________ * Contact your insurance carrier to make any changes in name, partnership, corporate status, or changes in the number of personal elections taken. Check with your insurance company to see if it will accept a copy of this form as notification of any changes or corrections to your insurance policy. Note: Submitting this notice to the Workers' Compensation Division will affect only your Workers' Benefit Fund assessment account for purposes of reporting. It will not affect your workers' compensation insurance coverage or claims liability. You need to contact your insurance provider to notify it of the changes. I understand that I am required to report and pay the Workers' Benefit Fund assessment at any time that the law requires or I choose to carry workers' compensation insurance coverage for myself or for any of my paid workers in Oregon. Mail your completed form to: X Signature Print name 150-211-158 (Rev. 12-13) Date Telephone number WC Assessments Unit DCBS/CSD/Financial Services PO Box 14480 Salem OR 97309-0405 American LegalNet, Inc. www.FormsWorkFlow.com