Fill and Sign the Oregon Program Employment Form

Workers’ Compensation Division Preferred Worker Program Obtained Employment Purchase Agreement (for Employer at Injury) If you have questions or need assistance completing this agreement, please contact the Preferred Worker Program in Salem, (503) 947-7588; toll-free, (800) 445-3948; fax, (503) 947-7581; TTY, (503) 947-7993. Employer Worker Legal name:       Name:       Doing business as:       Complete address:       Complete address:       (Street/P.O. box, city, state, ZIP)       (Street/P.O. box, city, state, ZIP)       Phone:       Phone:       Date of injury:       Contact person(s):       Job at the time of injury:       Federal tax ID no.:       This job (check one): Date the worker started this job:       New job Worker’s job title:       Modified job at injury The Workers’ Compensation Division and employer agree to the following: 1) The Workers’ Compensation Division will : a) Provide Obtained Employment Purchases in accordance with Oregon Administrative Rule Chapter 436, Division 110. b) Reserve the right to visit the worksite and to inspect and copy employer records to verify employment of the worker and otherwise determine compliance with this agreement. c) End this agreement at any time by written notice to the employer if the division determines, at its sole discretion, that the employer has not complied with the terms of this agreement or with state or federal law governing this employment. d) Provide an Authorization for Payment, Form 2344, or reimburse costs for purchases under this agreement. 2) The employer at injury will : a) Use an Authorization for Payment, Form 2344, to make purchases when applicable or send the division a legible copy of an invoice or receipt which indicates the items have been paid. All reimbursement requests must be submitted within one year of the agreement end date. b) Purchase only those items and services listed in this approved Obtained Employment Purchase Agreement . Changes are subject to division approval. c) Make no purchases after employment ends and return any unused Authorization for Payment forms to the division. d) Be subject to sanctions under OAR 436-110-0900 if the employer at injury has knowingly misrepresented information or otherwise falsely obtained assistance under this agreement. 440-2971 (7/05/DCBS/WCD/WEB) Page 1 Worker name: Error: Reference source not found Choose method of payment: Authorization for payment Reimbursement Both Vendor Description of assistance Unit(s)/ amounts Unit price Total price Program Use only                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Total, page 2: $       (To list additional items or services, please use page 3.) Total, page 3: $       Total agreement amount: $       This agreement is not valid until signed by an authorized representative of both parties. I hereby certify that the items listed in this agreement are required for all workers performing the job for which this worker is being employed and are not provided by the employer. I understand that these Obtained Employment Purchases will become the worker’s property, and that the division assumes no liability for repairing or replacing damaged or lost items and has no liability for injuries or damages caused by any Obtained Employment Purchase. By signing this agreement, I am affirming I have authority to act for and on behalf of the employer. Employer signature Date Employer title Send to: Preferred Worker Program, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 WCD USE ONLY Data entry Maximum approved under this agreement $ Effective date: End date: Worker’s WCD no. Certified true, accurate, correct, and an appropriate expenditure for this program. Program approval Date Employer’s WCD reg. no. 440-2971 (7/05/DCBS/WCD/WEB) Page 2 Worker name: (Additional items or services) Choose method of payment: Authorization for payment Reimbursement Both Vendor Description of assistance Unit(s)/ amounts Unit price Total price Program Use only                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Total, page 3: $       Employer signature Date 440-2971 (7/05/DCBS/WCD/WEB) Page 3