Supplemental Disability Election Notification
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Supplemental Disability Election Notification Form. This is a Oregon form and can be use in Insurer And Self Insurer Workers Comp.
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Tags: Supplemental Disability Election Notification, 3530, Oregon Workers Comp, Insurer And Self Insurer
SUPPLEMENTAL DISABILITY ELECTION
NOTIFICATION
elects the assigned processing agent
Insurer / self-insured employer name
regarding supplemental disability claims.
Insurer representative signature
Date
Insurer representative name (printed):
Title:
Phone:
If you have any questions regarding this form, you may call the Benefit Consultation Unit at (800) 452-0288.
Mail or deliver to:
Workers’ Compensation Division
Benefit Consultation Unit
350 Winter St. NE
P. O. Box 14480
Salem, OR 97309-0405
Or fax to (503) 947-7612
440-3530 (1/05/DCBS/WCD/WEB)
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