Fill and Sign the Preferred Worker Program Quarterly Claim Cost Reimbursement Request Oregon Form

Preferred Worker Program Quarterly Claim Cost Reimbursement Request Quarter Year Self-Insured Employer Insurance Company To: Department of Consumer and Business Services Workers’ Compensation Division, Performance Section Audit and Reimbursements Team 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 I certify that: 1) The costs listed are reimbursable claim costs under Oregon Administrative Rule 436-110-0330. (Note: The Workers’ Compensation Division will determine the appropriate administrative cost factor, as published in Bulletin 316, and apply it to the reimbursement.) 2) The claim costs reimbursed by the Preferred Worker Program are not and will not be included in the data that will affect employer rates or dividend eligibility. 3) The payments reported have been made in the amounts indicated and have not been previously requested. Reimbursement is requested in the amount of       . All costs must indicate the quarter and year of actual payment. From: Insurance company or self-insured employer (and service company, if applicable) name and address:       Signed: Date:             Name and title:       (Print or type)       Phone:       (Print or type) City State ZIP Preferred worker number * Claim status Insurer claim number Claimant name(s) (Alphabetical order: last, first) Date of new injury Date of hire for this job** Quarter/ Year of payment Claim costs Nondis. or Disabling Disability type*** Disability benefits Medical benefits Total costsN D TTD PPD                                                                                                                                                                                                                                                                                                                                                                                           Totals from Page 1:                   Totals from all additional pages:                   Totals:                   *Preferred worker number is the same as the WCD file number of the qualifying claim. **Required on first request. ***Temporary Total Disability (TTD); Permanent Partial Disability (PPD) 440-3014 (1/17/DCBS/WCD/WEB)