Fill and Sign the Oregon Reimbursement Form

Employer-at-Injury Program (EAIP) Reimbursement Request Form (See form instructions on reverse side) WCD use only (check one) Initial request Correction Additional request Amended Worker information (1) Worker name:       (7) Insurer claim no.:       (2) SSN:       (8) Accepted, date:       (3) Date of birth:       Denied, date:       Deferred (4) Date of injury:       (9) Disabling Nondisabling (5) WCD file no.:       (10) Employer:       (6) Address:       (11) Policy no.:       City/state:       ZIP:       (12) WCD employer no.:       EAIP information Concurrent injuries (OAR 436-105-0530) EAIP period: Start date:       End date:       EAIP period interrupts EAIP for claim no.: Wage subsidy information       Wage subsidy period: Start date:       End date:       EAIP period interrupted by EAIP for Reimbursement requested for       transitional work days. claim no.:       Purchase information Interruption start date:       (a) EAIP purchases (tuition, books and fees, tools, equipment, and clothing) or Interruption end date:       (b) worksite modification Type (a) or (b) Purchase date Itemized list of purchases Item cost                                                             Attach a separate list in same format, if necessary. Total request $       Summary (1) Total wages paid: $        x .45  $       (2) EAIP purchases ( complete above) .......................................................................... Total reimbursement: $       (3) Worksite modification ( complete above) ............................................................... Total reimbursement: $       (4) Administrative cost (flat rate of $120) r eimbursed on initial request only: .............................................. $       Total reimbursement requested: $       Certifications and reimbursement information: I certify either that I am an insurer, self-insured employer, or service company or that the insurer, self-insured employer, or service company authorized me to submit this reimbursement request on their behalf. I certify that the employer and worker qualify for the Employer-at-Injury Program, and that all information cited on this form is in accordance with OAR 436-105. Insurance company/self-insured employer:       Service company (if applicable):       Send reimbursement to this address:       City/state:       ZIP:       Insurer representative name (please print or type):       Signature: Phone:       Email:       Date:       Send to: Workers’ Compensation Division, Performance Section, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 Or fax to 503-947-7725 440-2360 (7/18/DCBS/WCD/WEB) Employer-at-Injury Program (EAIP) Reimbursement Request Form Instructions Initial request: Check this box if this is the first request for reimbursement for this claim and EAIP period. (Initial requests must be a minimum of $100 , not including the administrative cost.) Correction: Check this box if correcting a form returned by the division for being incomplete or containing an error. Additional request: Check this box if there was a prior approved EAIP request for this claim within the same EAIP period. (There is no administrative cost allowed on additional requests.) Amended: Check this box if you are amending a previously processed request. Worker information (1) Worker name: Enter the worker’s legal name at the time of injury. (2) SSN: Enter the worker’s complete Social Security number. (3) Date of birth: Enter the worker’s date of birth. (4) Date of injury: Enter the date of injury provided by the insurer on the 801/1502/Notice of Acceptance/Denial. (5) WCD file no.: Enter the file number provided by the Workers’ Compensation Division. (Leave blank if unknown.) (6) Address: Enter the worker’s current address, including city, state, and ZIP code. (7) Insurer claim no.: Enter the claim number the insurer assigned to the injured worker’s claim. (If the insurer has changed a previous claim number, provide both and write “New” in front of the new claim number.) (8) Accepted: If the claim is accepted, check this box and enter the date it was accepted as stated in the Notice of Acceptance. Denied: If the claim is denied, check this box and enter the date it was denied as stated in the Notice of Denial. Deferred: Check this box if the claim has not been accepted or denied. Reimbursement may be requested up to but not after the denial date. (9) Disabling: Check this box if this claim is disabling. Nondisabling: Check this box if this claim is nondisabling. Note: A “disabling” or “nondisabling” status must be designated on both accepted and denied claims. (10) Employer: Enter the legal name of the employer at the time of injury or aggravation. (11) Policy no.: Enter the policy number provided by the insurer. (12) WCD employer no.: Enter the WCD number assigned to the employer. You can look up the WCD employer number at http://www4.cbs.state.or.us/ex/wcd/employer/ . If you cannot locate the number, call WCD at 503-947-7814 or email wcd.employerinfo@oregon.gov . EAIP information EAIP period start date: Enter the date the worker was released to modified work. EAIP period end date: Enter the date the claim closes or the worker is no longer eligible under OAR 436-105-0512. Concurrent injuries: Enter the other claim number that is affected by this claim’s Employer-at-Injury Program. Wage subsidy information Wage subsidy period start date: Enter the date the worker returned to modified work. Wage subsidy period end date: Enter the date the worker ends transitional work. Reimbursement requested for transitional work days: Enter the number of transitional work days (may not exceed 66 work days in a 24-consecutive month period). Purchase information Enter the details of any purchases or modifications made: (a) EAIP purchase (tuition, books and fees, tools, equipment, and clothing) or (b) Worksite modification. Summary (1) Enter the total wages paid and multiply x .45. (2) EAIP purchases/total reimbursement: Enter the total of (a) purchases from the itemized list, if applicable. (3) Worksite modification/total reimbursement: Enter the total of (b) purchases from the itemized list, if applicable. (4) Administrative cost reimbursed on initial request only: Enter the $120 administrative cost for the initial request, in accordance with OAR 436-105-0540(2). Certifications and reimbursement information (See 436-105-0500: Insurer Participation in the EAIP.)  Insurance company/self-insured employer: Enter the insurance company or self-insured employer responsible for the workers’ compensation claim at the time of injury .  Service company: Enter the service company, if applicable.  Send reimbursement to this address: Enter the address where funds are to be sent.  Insurer representative name and signature: Enter the name of the person completing this form and sign the form.  Phone number, email, and date: Enter the representative’s phone number, email address, and the date the form is mailed. Questions If you have reimbursement questions, call 503-947-7751. If you have program questions , call 800-445-3948 (toll-free). 440-2360 (7/18/DCBS/WCD/WEB)