CIS Servicing Group Enrollment Form

ENROLLMENT FORM

We are members in good standing of the Association of Oregon Counties or the League of Oregon Cities.

We wish to enroll in the CIS Servicing Group effective July 1, 2021.

We understand that our enrollment will not involve any additional expense to us or increase premiums to participate in the CIS Servicing Group. This enrollment will remain in effect until we revoke it in writing.

Entities A - P
Please select your entity from the dropdown list.

Entities R - Y
Please select your entity from the dropdown list.

First Name *

Last Name *

Title *

Email Address *

Date * +

Signature *

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Optional CIS Rapid Care Hotline Participation

CIS is continuing the popular and cost-cutting program, Rapid Care for participants of the CIS Servicing Group.

Rapid Care is a telephone hotline where injured employees talk to a nurse who provides helpful information and completes the employee portion of the 801. The nurse does not direct medical care.

The cost is $115 per claims event. CIS will cover the cost for members who had CIS workers’ compensation coverage in FY 2020-21. All others will be charged annually.

Click HERE to learn more about how Rapid Care works.

We want to participate in the Rapid Care Hotline. *

Yes

No