Get the free Form 3622, Workers' Compensation Forms Rates For ... - Oregon.gov - oregon

Department of Consumer & Business Services Oregon Insurance Division 5 350 Winter St. NE Salem, Oregon 97301-3883 Phone (503) 947-7983 WORKERS COMPENSATION FORMS RATES FOR ADVISORY LOSS COST MODIFICATION

How to fill out form 3622 workers39 compensation

How to fill out form 3622 workersamp39 compensation:

1. Gather all necessary information: Before filling out form 3622 workersamp39 compensation, make sure you have all the necessary information handy. This includes the employee's personal details, such as their full name, address, and social security number. You will also need information about the employer, such as their name, address, and contact information.
2. Provide details of the injury: In section A of the form, you will need to describe the nature of the injury or illness that the employee is claiming compensation for. Be as specific as possible, detailing the date, time, and location of the incident. It's important to accurately describe how the injury occurred and the extent of the resulting disability.
3. Employment details: In section B, provide information about the employee's employment status. This includes their job title, date of hire, and current wage rate. You will also need to provide details about any previous workers' compensation claims the employee has made.
4. Medical treatment: In section C, provide information about the medical treatment the employee has received for their injury. This includes the names and addresses of healthcare providers, as well as the dates and details of any medical procedures or treatments.
5. Wage information: In section D, you will need to provide details about the employee's earnings and the time they have missed from work due to the injury. This includes information about their average weekly wage, any overtime or bonuses, and the number of hours they typically work.
6. Sign and submit the form: After completing all the necessary sections of form 3622 workersamp39 compensation, both the employee and the employer need to sign the form. Make sure to double-check all the information before submitting it to the appropriate authorities.

Who needs form 3622 workersamp39 compensation?

Form 3622 workersamp39 compensation is typically needed by employees who have been injured or have developed an illness in the course of their employment. It allows them to claim workers' compensation benefits, including medical treatment and wage replacement, if they are unable to work due to the injury or illness. This form is generally required by employers, insurance companies, and other parties involved in the workers' compensation process to properly assess and process the employee's claim.

For pdfFiller’s FAQs

What is form 3622 workers39 compensation?

Form 3622 workers' compensation is a document used to report work-related injuries or illnesses and to ensure that employees receive the benefits they are entitled to.

Who is required to file form 3622 workers39 compensation?

Employers are required to file form 3622 workers' compensation for any employees who have suffered a work-related injury or illness.

How to fill out form 3622 workers39 compensation?

Form 3622 workers' compensation should be filled out completely and accurately, providing all necessary information about the employee, the injury or illness, and any treatment received.

What is the purpose of form 3622 workers39 compensation?

The purpose of form 3622 workers' compensation is to ensure that employees receive the benefits they are entitled to for work-related injuries or illnesses.

What information must be reported on form 3622 workers39 compensation?

Information that must be reported on form 3622 workers' compensation includes details about the employee, the injury or illness, and any medical treatment received.

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