Worker Leasing Termination Notice (Cancels a client222s proof of coverage) Internal use only Received date: Approved Rejected A worker leasing company [also known as a Professional Employer Organization (PEO)] may terminate its obligation to provide workers222 compensation coverage for a client by mailing a Termination Notice to the client. The worker leasing company must also file a copy with the Oregon Workers222 Compensation Division and its insurer within 30 days after the final date of the lease arrangement, or its knowledge that the client obtained other coverage. The worker leasing company may substitute its own form provided it meets the requirements under OAR 436-180-0110(3). [ORS 656.850(5)] Please fax this notice to 503-947-7820. For other filing options, call 503-947-7675. The worker leasing company is responsible to remove Notice of Compliance postings (Form 1188) for all client worksites when the worker leasing company ceases to provide workers222 compensation coverage. [ORS 656.056(2)] REQUESTED TERMINATION EFFECTIVE DATE * : ( C overage end date for a client in Oregon) *Regardless of the effective date above, the termination will not be effective until the 30th day after the notice is received by the division or the effective date, whichever is later. CLIENT INFORMATION (provide ONLY client information in this section) Business entity legal name: FEIN : (do NOT use SSNs ) Assumed business name (dba ), if any: Client phone: Client email, if known: Oregon location address: or Home - based employees only Client mailing address , if different : REASON FOR TERM I NATION Client relationship continues, but: Client relationship ended: Client no longer has Oregon employees Non payment or o ther obligation not met Client now has client - purchased policy Client out of business, retired, or deceased Insurer name : Changed PEO; new PEO name, if known: Polic y number: Client changed FEIN (new Form 2465 required) Client left PEO; unknown reason Other: Other: WORKER LEASING COMPANY INFORMATION Legal name: dba (if used in Oregon) Oregon leasing license no.: WLC000 FEIN: The worker leasing company name above, by signing this Termination Notice and filing a copy with the Workers222 Compensation Division, hereby certifies that notice of this termination has been provided to the workers222 compensation carrier and has been given by mail, addressed to the client at its last - known address, as required by OAR 436 - 180 - 0110(3)(b) . Authorized representative name (please print) Email Phone Signature of auth orized representative Date 440 - 3271 ( 8 /18/DCBS/WCD/WEB) 3271 American LegalNet, Inc. www.FormsWorkFlow.com