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STATE OF OREGON

BOILER/PRESSURE VESSEL SAFETY PROGRAM

AGENCY OF RECORD CHANGE

NOTICE OF NEW BUSINESS OR DISCONTINUANCE

Mandatory Information Required to track Agency of Record Information


*ALL FIELDS ARE MANDATORY.

Date of Notice

Notice of:

POLICY INFORMATION

Policy Effective / Cancel Date:
Name of Insured:
Insured Address:
Insured City:
Insured State:
Insured Zip Code:
Insured County:


LOCATION INFORMATION

Location Name:
Location Address:
Location City:
Location State:
Location Zip Code:
Location County:


BOILER / VESSEL INFORMATION


(National Board or State Jurisdiction Number Mandatory)

Object Description:
National Board Number:
State Jurisdiction Number:
Manufacturer:


Company Submitting and Phone# :
E-Mail :