Workers’ Benefit Fund Assessment
                            Corrections and Changes Notification

• Use this form to update your Workers’ Benefit Fund assessment account*
Business name                                                            Oregon Business Identification Number (BIN)

Corrections (enter corrected information)
Is this address to be used for forms only?       Yes   No
Business name                                                                        BIN

Mailing address                                                                      Federal Employer Identification Number (FEIN)

City                                            State           ZIP code             Telephone number

Changes in Status (check and complete all that apply)
                                                                                                     DCBS use only
   1. No longer in business. Effective date of closure: _________________________________________    RC02 __________

   2. Still in business, but have no paid employees. Effective date: ____________________________
    I maintain workers’ compensation insurance coverage:
           Not for myself and/or corporate officers, but in case I hire employees.                   RC06 __________
           To cover myself and/or corporate officers exclusively; no employees.                      A/L

           To cover volunteer workers exclusively.                                                   RC06 __________

   3. I no longer have workers’ compensation insurance coverage:
           I have canceled my workers’ compensation insurance coverage.                              RC02 __________
           Effective date of cancellation: _______________________________________________________
           I will be canceling my workers’ compensation insurance coverage.                          RC02 __________
           Effective date of cancellation: _______________________________________________________

   4. I now use leased employees only. Effective date:  _______________________________________      RC05 __________

   5. Other. Please explain: _________________________________________________________________

* Contact your insurance carrier to make any changes in name, partnership, corporate status, or changes in the 
 number of personal elections taken. Check with your insurance company to see if it will accept a copy of this form as 
 notification of any changes or corrections to your insurance policy.
Note: Submitting this notice to the Workers’ Compensation Division will affect only your Workers’ Benefit Fund assessment 
account for purposes of reporting. It will not affect your workers’ compensation insurance coverage or claims liability. You 
need to contact your insurance provider to notify it of the changes.

I understand that I am required to report and pay the Workers’  
Benefit Fund assessment at any time that the law requires or I   Mail your completed form to:
choose to carry workers’ compensation insurance coverage for 
myself or for any of my paid workers in Oregon.                          WC Assessments Unit
                                                                         DCBS/CSD/Financial Services
X
Signature                                       Date                     PO Box 14480
                                                                         Salem OR 97309-0405
Print name                  Telephone number
150-211-158 (Rev. 12-13)