| Instructions |
- Complete all required
fields on this form
marked with an *.
- Review all items for
accuracy. Double check
phone/fax numbers.
- Click the SUBMIT CERTIFICATE
REQUEST button at
the bottom of this
form.
|
| Notice |
- All requests will
be processed within
3 business days.
- For questions about
this form or online
certificates please
contact:
By Phone: 503-968-6300
weekdays between the
hours of 8 a.m. and
4:30 p.m.
By Fax: 503-968-6305
|
| Person
Requesting Certificate |
| Full Name: |
|
| Phone Number:
|
|
|
|
Member Information |
| Company
Name:* |
|
| Contact
Person Name:* |
|
| Contact
Phone Number:* |
|
| Contact
E-mail Address:* |
|
| |
| Issue
Certificate of Coverage to |
| Certholder
Name:* |
|
| Attention: |
|
| Address
Line 1:* |
|
| Address
Line 2: |
|
| City/State/Zip:* |
|
| Job/Location
Description |
| Is
the job located in a state
other than Oregon?* Yes
No
|
| |
Enter
street address, city,
state, zip, lot/subdivision,
unit number etc.
Press ENTER to start a
new line.
|
| Special
Options |
 |
"Special Options"
Explain
below if the "Special
Options" box is checked
PLEASE NOTE: The option
to list an additional
certificate holder is
not available under Workers'
Compensation Insurance.
|
| |
| Additional
Comments |
|
| |
|
| |
| Fax
Options: |
Do
you need this
certificate faxed?:
|
Fax Numbers
are ignored unless a corresponding
box is checked. Please
include area code: xxx-xxx-xxxx
|
|
Certholder
|
Fax
Number
|
|
Member |
Fax Number
|
|
|
|
| (If
any fax option is chosen,
then we will not mail a separate
paper copy) |
