Worker Leasing Update Notice (Change of client information) Internal use only Received date: Approved Rejected This notice is used to update a client222s information on an active Worker Leasing Notice (Form 2465). Changes that should be reported include business legal name, federal employer identification number (FEIN) correction, client address, addition or deletion of assumed business name, and Oregon workers222 compensation coverage effective date correction. You must notify the Oregon Workers222 Compensation Division and your insurer within 30 days after the effective date of a change or knowledge that a correction is needed. [OAR 436-180-0110(2)] Please fax this notice to 503-947-7820. For other filing options, call 503-947-7675. CLIENT INFORMATION (provide ONLY client information in this section) Client222s current legal name: FEIN : (do NOT use SSNs) CHANGE BEING REPORTED Effective date Client name change Former name: Assumed business name added deleted (name being added/deleted) Client222s principal business address: (updated address) Client222s mailing ad dress: (updated address) Client222s phone number: Client222s email address: Co rrection to effective date Corrected effective date: Reason: Correction to FEIN Incorrect FEIN: Reason: Use only for FEIN correction. If a client changes its FEIN, submit a Notice of Termination (Form 3271) to cancel Oregon proof of coverage for the prior FEIN/entity and file a new Worker Leasing Notice (Form 2465) to establish Oregon proof of coverage for the new FEIN/entity. Other change (specify): WORKER LEASING COMPANY INFORMATION Legal name: dba (if used in Oregon) Oregon leasing license no.: WLC000 FEIN: Authorized representative name (please print) Email Phone Signature of authorized representative Date 3270 440 - 3270 ( 8 /18/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com