[DAS_Centralized_PERS_Services_Team] Worker's Compensation Certification Form

[VIDAL Trudy * DAS]

Happy Friday Afternoon,

DAS Centralized PERS Services Team received notification that PERS has a Workers' Compensation Certification form available on their website https://www.oregon.gov/pers/mem/docs/form/679.pdf . This form is for Tier One and Tier Two employees to initiate a request for service credit during the time they were on Leave Without Pay (LWOP) for a workers' compensation or disability claim.  OPSRP employees do not qualify for this certification.  Employees need to turn this form into their Employer for an employer certification.  The employer should then send this form to the DAS Centralized PERS Services Team for further processing with PERS.  The form can either be sent through the shuttle to our address at 155 Cottage St NE, Salem, OR 97301 or faxed to our office at 503-378-4596.  Please do not email these forms as they contain personally identifiable information.  If you have further questions regarding this form, please contact your assigned CPERS analyst.

Trudy Vidal, CPA
Financial Business Systems Manager
Enterprise Goods and Services
Department of Administrative Services
Telephone:  503-373-0170


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