Request For Reimbursement From Retroactive Program
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Request For Reimbursement From Retroactive Program Form. This is a Oregon form and can be use in Insurer And Self Insurer Workers Comp.
Loading PDF...
Tags: Request For Reimbursement From Retroactive Program, 3285, Oregon Workers Comp, Insurer And Self Insurer
REQUEST FOR REIMBURSEMENT FROM THE RETROACTIVE PROGRAM
To:
Department of Consumer & Business Services
Workers’ Compensation Division
Compliance Section
350 Winter St. NE
P.O. Box 14480
Salem, OR 97309-0405
FATAL BENEFITS
A.
B.
For the period
C.
D.
F.
$0.00
E.
F.
D.
E.
F.
G.
H.
SUBTOTAL:
TEMPORARY TOTAL DISABILITY
A.
B.
C.
D.
E.
SUBTOTAL:
PERMANENT TOTAL DISABILITY
A.
B.
C.
through
$0.00
G.
H.
-
SUBTOTAL:
$0.00
TOTAL THIS QUARTER:
$0.00
I certify that the payments reported have been made in the amounts indicated and have not been previously reimbursed.
.
Reimbursement is requested in the amount of
Mail reimbursement to insurer:
TPA:
Address:
Signed:
Title:
Print or type name:
Telephone No:
(
)
440-3285 (9/06/DCBS/WCD/WEB)
American LegalNet, Inc.
www.FormsWorkflow.com
