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Workers' Compensation Division (WCD)

Department

Independent Medical Exam

Ombudsmen

Performance Measures

Workers' Benefit Fund

Jenni Bertels
503-947-7615

Affidavit request form

When you need notarized information on workers’ compensation coverage dates for an employer, fill in the form below. If you are concerned about your privacy and the information we collect on this site, please read our privacy statement.
Employer name:
DBA/ABN:
Address 1:
Address 2:
City:
State:
ZIP:
Phone number:
WCD employer number:
Coverage dates needed:
Requester’s name:
Company name:
Address 1:
Address 2:
City:
State:
ZIP:
Phone number:
Fax number:
E-mail address:
Additional comments:

If you have questions about the information contained in this document, please contact Jenni Bertels, 503-947-7615.

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