Self-Insured Employer Report of Losses Experience Rating Period Forms
| Form Name | Self-Insured Employer Report of Losses Experience Rating Period |
| Form # | 440-2809 |
| Form Revision | 1/25 |
| Category | Forms » Insurance |
| Downloads | |
| Form State | Oregon |
| Language | English |
| State Description | For self-insured employer's report of claims loss data to DCBS for calculation of annual experience rating modifications, security deposits, and retrospective rating plan adjustments. |
| Claimwire Description | n/a |