Fill and Sign the Claim Reserve Worksheet Oregon Form

Workers’ Compensation Division Claim Reserve Worksheet Self-insured employer:       Worker’s name:       Sex: M/F       Date of injury:       Date of birth:       Claim number:       Average weekly wage at D/I:       Valuation date: Jan. 1,      SI employer notes:       Total paid Outstanding reserves Indemnity TTD/TPD paid:       Future TTD/TPD       (# weeks) X       (TTD rate): $0.00 PPD awarded — paid       (percent scheduled/unscheduled):       PPD awarded — unpaid       Estimated future PPD       (percent scheduled/unscheduled):       Medical Medical paid:       Future medical: (show burial allowance on reverse side only):       If applicable, life expectancy       (yrs.) X $       : $0.00 Vocational assistance Vocational assistance paid:       Future vocational assistance: TTD while in ATP (weeks) X       (TTD rate): $       $0.00 Other vocational assistance costs       Other Litigation — potential liability:             PTD/fatal benefits (see reverse side for calculation of outstanding reserves)       $0.00 Totals SIR $       Subtotals: $0.00 $0.00 WDP       % $0.00 $0.00 Total paid, outstanding reserves $0.00 $0.00 Total incurred losses: Total paid + outstanding reserves = $0.00 440-2808 (1/17/DCBS/WCD/WEB) 2808 PTD/Fatal Reserving Worksheet (complete both sides) PTD Benefits — Complete PTD and Dependents sections PTD effective date:       Future anticipated PTD benefits D.O.B. Remaining years Months Monthly statutory rate Outstanding reserves       Workers       X 12 X      $0.00       Spouse       X 12 X       $0.00       Widow(er)       X 12 X       $0.00 Social Security offset effective date:       # Months to worker’s full retirement age Monthly offset amount up to max. of stat. rate       X       = $0.00 Burial allowance (in accordance with law in effect at date of injury)       Fatal benefits — Complete Fatal and Dependents sections Fatal benefits effective date:       Future anticipated fatal benefits D.O.B. Remaining years Months Monthly statutory rate       Widow(er)       X 12 X       $0.00 Widow(er) without child (DOI eff. 9/20/85)       X 12 X       $0.00 Dependents — PTD or fatal D.O.B. Remaining months Monthly statutory rate       Child #1       X       $0.00       Child #2       X       $0.00       Child #3       X       $0.00       Child #4       X       $0.00 Total (carry forward to front of worksheet, “Other” section) $0.00 440-2808 (1/17/DCBS/WCD/WEB)