Fill and Sign the Oregon Worker Program 497323809 Form

Preferred Worker Program Premium Exemption and Wage Subsidy 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 worker started job:       New job Worker’s job title:       Modified job at injury The Workers’ Compensation Division and the employer agree to the following: 1) The Workers’ Compensation Division will: a) Provide premium exemption and wage subsidy assistance in accordance with Oregon Administrative Rules Chapter 436, Division 110. b) Reimburse the employer 50 percent of the wages as defined in OAR 436-110-0005 paid the worker for 183 calendar days from the start date of this agreement. If the worker has an exceptional disability as defined in OAR 436-110-0005, the wage subsidy duration is 365 days with a reimbursement rate of 75 percent. c) Exempt the employer from paying workers’ compensation insurance premiums and premium assessments on this worker for a period of three years from the start date of this agreement, or until the date the job named in (2)(b) of this agreement ends, whichever occurs first. d) 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. e) 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. f) Send the employer a copy of this agreement and a Wage Subsidy Reimbursement Request form when this agreement is approved. 2) The employer will: a) Maintain Oregon workers’ compensation insurance coverage as long as that coverage is required by law. b) Employ the worker as a (job title)       according to the same business practices and policies affecting all other employees. 440-2970 (5/06/DCBS/WCD/WEB) Page 1 c) Submit a completed Wage Subsidy Reimbursement Request to the division to obtain reimbursement. Requests may be submitted as often as every two weeks. All requests must be submitted within one year of the agreement end date or reimbursement will not be made. d) Repay all costs incurred by the division under this agreement, including all legal costs and attorney fees, if the division finds the employer falsely obtained re-employment assistance or if the division subsequently prevails in any legal action against the employer arising out of this agreement. 3) Estimate of wage subsidy amount (This estimate is only for the purpose of determining the maximum amount of this agreement. Reimbursements to the employer will be 50 percent of the gross wages actually paid during this agreement period, not to exceed the maximum amount of this agreement): a) Wages to be paid the worker in the next six months. When estimating wages, include expected raises, holiday pay, paid leave , overtime, company-provided housing/rent (reasonable value) .................................... $       b) Commission expected in next six months ..................................................................................... $       c) Mileage paid as part of the wage in next six months (Do not include if reimbursed to the worker.) ............................................................................... $       d) Bonus pay provided as part of a written or verbal employment contract to increase the worker’s wage, such as monthly performance bonuses. (End-of-year and other one-time bonuses paid at the employer’s discretion are not reimbursable.) ................................................................................................... $       e) Total of lines (a) + (b) + (c) + (d) .................................................................................................. $       f) Line (e) divided by 2 equals the estimated total reimbursement .................................................... $       Are these wages subsidized by any other source? .......................................................................... Yes No This agreement is not valid until signed by an authorized representative of both parties. To the best of my knowledge, this job is within the worker’s injury-caused restrictions. I understand the division assumes no liability for payment of wages. By signing this agreement, I am affirming I have authority to act for and on behalf of the employer. Employer signature Date Send to: Preferred Worker Program, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 WCD USE ONLY Data entry Maximum wage subsidy reimbursement under this agreement $ Wage subsidy effective dates: Start date: End date: Premium exemption effective dates: Start date: End date: Worker’s WCD No.: Certified true, accurate, correct, and an appropriate expenditure for this program. Program approval Date WCD Reg. No. 440-2970 (5/06/DCBS/WCD/WEB) Page 2