Cancellation Notice Insert name of insurer and address where policy/coverage information is available: This notice is to inform you that your workers compensation policy and the related Guaranty Contract is hereby canceled as of the hour and date shown below. Prospective coverage liability of the insurer and related Guaranty Contract shall cease as of the time shown, without further notice. Employers legal name and mailing address: Policy no.: FEIN: BIN or WCD no.: Cancellation effective at midnight: Reason for cancellation: Not renewing a specific premium category No longer employing in Oregon Out of business Nonpayment of premium Coverage placed elsewhere: New carrier name: Policy no.: Effective date: Other: This notice is being sent to the employer and to the Department of Consumer and Business Services. Date cancellation Insurer representative signature: mailed to employer: Contact name and phone: ( ) 440-3216 (3/04/DCBS/WCD/WEB)