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JAN.09 '97 02~39PM EARRETT EUSINESS ~ P•2 <br /> <br /><<~~~t ~~~t.~~~I'~~v~~ ~~~ <br />NOTICE OF OREGON WORKERS' COMPENSATION COVERAGE <br />DATE: ]anuary 9, 1997 <br />PARTIFS Barrett Business Services, Inc. ("Barrett}" <br />4949 S.W. Macadam Ave., Suite 1 <br />Portland, Oregon 97201 <br />(503} 243-2444 <br />("Client") <br />Capitol City Moving & Storage <br />1465 Iohnson Street NE <br />Salem, Oregon 97303 <br />Policy Nbr: 17887 <br />A. Client has entered into an Employee Leasing Agreement with Bazrett dated 01101190; <br />B. Barrett and Client are joint employers of employees leaseci to Client, and, <br />C. Under contract terms, Bazrett is a complying self-insured employer that provides <br />workers' compe~nsation for the employees leased to Client, which may be due the <br />subject workers, in accordance with the Worloers' Compensation Law, Chapter 656, <br />Oregon Revised Statutes: <br />Oregon WCD No. b75153-1 <br />Registradon Self Insured No. 1063 <br />Effective August 17, 1987 (undl canceled or revoked) <br />Limits of Coverage: Statutory <br />Retention Each Occurrence: $350,000 <br />To verify compliance, please contact The Oregon Department of Consumer and Business <br />Services, Bmployer Indexing, (503) 945-7886. <br />Uebhie Jackson <br />Barrett Business Services, Inc. <br />Loss Control <br />.5+~'~.~ruf.~~_ ~'~u.r:~y <br />'tOQQ . I ,~rfl. ir~/lirn~i~nr. ~ih~~~iis~, • , liii/i . / • «~~iv~i~ /Q~~~ (1 ~?di) / • i:/1.Y/c~il o ~t d~d • i .U~vi i i.p- o d ~ 4 _ ~_?.. . ,-. . ~, ~.. .. ~ , ..... <br />