Contractor Data and Certification. Contractor Information. Contractor shall provide information set forth below. This information is requested pursuant to ORS 305.385. If Contractor is self-insured for any of the Insurance Requirements specified in Exhibit F of this Contract, Contractor may so indicate by: (i) writing “Self-Insured” on the appropriate line(s); and (ii) delivering, via Administrative Notice, a certificate of insurance as required under Ex. F, Sec. 9. Please print or type the following information NAME (exactly as filed with the IRS): Street Address: City, state, zip code: Telephone: ( ) Facsimile Number: ( ) E-mail address: Social security number or FEIN Is Contractor a nonresident alien, as defined in 26 U.S.C. § 7701(b)(1)? (Check one box): YES NO Contractor Proof of Insurance: All insurance listed must be in effect at the time of provision of services under this Contract. Professional Liability Insurance Company Policy # Expiration Date: Commercial General Liability Insurance Company Policy # Expiration Date: Auto Insurance Company Policy # Expiration Date: Workers’ Compensation: Does Contractor have any subject workers, as defined in ORS 656.027? (Check one box): YES NO If YES, provide the following information: Workers’ Compensation Insurance Company: Policy # Expiration Date: Contractor shall provide proof of Insurance upon request by OHA or OHA designee. Form of Legal Entity: (Check one box): Professional Corporation Nonprofit Corporation Insurance Corporation Limited Liability Company Business Corporation
Contractor Data and Certification. Contractor Tax Identification and Insurance Information. Contractor shall provide Contractor’s Social Security number or Contractor’s federal tax ID number and the additional information set forth below. This information is requested pursuant to ORS 305.385 and OAR 125-020-0410(3). Social Security Numbers provided pursuant to this Section will be used for the administration of state, federal and local tax laws. Please print and/or type the following information: Name (exactly as filed with the IRS) Address Telephone: ( ) - Facsimile: ( ) - Citizenship (check one): Nonresident alien [ ] YES [ ] No Proof of Insurance: Insurance Company Policy # Expiration Date: Auto Insurance Company . Policy # Expiration Date: Business Designation (check one): [ ] Professional Corporation [ ] Partnership [ ] Limited Partnership [ ] Limited Liability Company [ ] Limited Liability Partnership [ ] Corporation [ ] Sole Proprietorship [ ] Other Social Security # or Federal Tax I.D.# Above Payment and Insurance information must be provided prior to contract approval. Contractor shall provide proof of Insurance upon request by DEPARTMENT or DEPARTMENT designee. DEPARTMENT may report the information set forth above to the Internal Revenue Service (IRS) under the name and social security number or taxpayer identification number provided.
Contractor Data and Certification. Contractor Information. Contractor shall provide the information required as set forth below. This information is requested pursuant to ORS 305.385. If Contractor is self-insured for any of the Insurance Requirements specified in Ex. F of this Contract, Contractor may so indicate by: (i) writing “Self-Insured” on the appropriate line(s) below; and (ii) delivering, via Administrative Notice, a certificate of insurance as required under Ex. F, Sec. 14. Please print or type the following information: Name (exactly as filed with the IRS) Street Address City, State, Zip Code Telephone Facsimile Number E-mail address: Federal Employer Identification Number (FEIN) Is Contractor a nonresident alien, as defined in 26 U.S.C. § 7701(b)(1)? YES NO
Contractor Data and Certification
