OR WC Proof Of Coverage Revised

                               
Portland, OR (CompNewsNetwork) - Insurers may only use these forms to make changes to guaranty contracts filed for policies effective before
July 1, 2009. For all policies effective on or after July 1, 2009, insurers must report workers' compensation
proof of coverage information via electronic data interchange (EDI) under OAR 436-160.

1. Guaranty Contract – Form 440-821
An insurer must file a guaranty contract with the Workers' Compensation Division for policies with coverage
effective before July 1, 2009 according to ORS 656.419 and OAR 436-050-0060. Insurers must use Form 821
unless the insurer has received approval from the division to report electronically under OAR 436-160.

2. Guaranty Contract Endorsement – Form 440-3215
An insurer may change information on a guaranty contract, except for a change in legal entity or a change in
insurance carrier, by filing an endorsement to the guaranty contract (OAR 436-160-0350). Insurers may use the
attached sample Form 3215 or develop their own endorsement form.

3. Termination of a Guaranty Contract – Form 440-3216
An insurer may terminate liability on its guaranty contract by giving notice as provided under ORS 656.427 and
OAR 436-160-0360. Insurers may use the attached sample Form 3216 or develop their own form for the
director's notice.

4. Guaranty Contract Reinstatement Notice – Form 440-3217
An insurer may reinstate its guaranty contract as provided under OAR 436-160-0350 if coverage has not lapsed
and the policy is for coverage effective before July 1, 2009. Insurers may use the attached sample Form 3217 or
develop their own reinstatement notice. If submitting data to the division electronically, follow instructions in
OAR 436-160-0350. If the coverage period has lapsed and the policy is for coverage effective before July 1,
2009, the insurer must file a new guaranty contract.

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