When you are starting a new business, there are a lot of things that you need to take into consideration. One of the most important is filing your taxes correctly and on time. The good news is that there are a lot of resources available to help you do this, including Form Wc9552A. This form is specifically designed for businesses, and it can help you file your taxes in a way that is both accurate and easy to understand. Make sure to use this form when preparing your business taxes, and you can be sure that everything will be taken care of properly.
Below is some information that may be useful if you are aiming to find out the time it'll take you to complete form wc9552a and the number of PDF pages it includes.
Question | Answer |
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Form Name | Form Wc9552A |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | Ev, blank 801 form, Oregon, insurer |
Insert
Report of Job Injury or Illness
Workers’ compensation claim
Worker
To make a claim for a
Date of |
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Date you |
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Time you began work |
a.m. |
Regularly scheduled |
DEPT USE: |
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injury or illness: |
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left work: |
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on day of injury: |
p.m. |
days off: |
Emp |
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Time of injury |
a.m. |
Time you |
a.m. |
Check here if you have more than one |
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M T W T F S S |
Ins |
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or illness: |
p.m. |
left work: |
p.m. |
job: |
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What is your illness or injury? What part of the body? Which side? (Example: Sprained right foot) |
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Left |
Right |
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What caused it? What were you doing? Include vehicle, machinery, or tool used. (Example: Fell 10 feet when climbing an |
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extension ladder carrying a |
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2src |
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Information ABOVE this line; date of death, if death occurred; and Oregon OSHA case log number must be released to an authorized worker representative upon request.
Your legal name: |
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Language preference: |
Birthdate: |
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Gender: M |
F |
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Your mailing address: |
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Home phone: |
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Social Security no. (see Form 3283): |
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Occupation: |
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Work phone: |
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Names of witnesses: |
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Name and phone number of health insurance company: |
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Name and address of health care provider who treated you for the |
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injury or illness you are now reporting: |
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Were you hospitalized overnight? |
Yes |
No |
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Were you treated in the emergency room? |
Yes |
No |
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By my signature, I am making a claim for workers’ compensation benefits. The above information is true to the best of my knowledge and belief. I authorize health care providers and other custodians of claim records to release relevant medical records to the workers’ compensation insurer,
Worker |
Completed by |
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signature: |
(please print): |
Date: |
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Employer
Complete the rest of this form and give a copy of the form to the worker. Notify your workers’ compensation insurance company within five days of knowledge of the claim. Even if the worker does not wish to file a claim, maintain a copy of this form.
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Employer legal |
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business name: |
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Phone: |
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FEIN: |
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If worker leasing company, |
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Client |
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list client business name: |
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FEIN: |
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Address of principal place |
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Insurance |
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of business (not P.O. Box): |
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policy no.: |
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Street address from which |
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Nature of business in which worker |
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worker is/was supervised: |
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ZIP: |
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is/was supervised: |
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Address where |
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event occurred: |
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Was injury caused by failure of a machine or product, or by a person other than the injured worker? |
Yes |
No |
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Were other workers injured? |
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Yes |
No |
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OSHA 300 log case no: |
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Date employer |
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Date worker |
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Worker’s |
Date worker |
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If fatal, date |
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knew of claim: |
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returned to work: |
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weekly wage: $ |
hired: |
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of death: |
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Employer |
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Name and title |
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signature: |
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(please print): |
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Date: |
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OSHA requirements: |
801 |
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hours. Report any accident that results in overnight hospitalization within 24 hours to Oregon OSHA. Call |
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WC9552A