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

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

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Insurer       Preferred Worker Program Quarterly Claim Cost Reimbursement Request Quarter Year 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 (Transfer to Page 1.):                   440-3014 – extra page (05/15/DCBS/WCD/WEB)

Valuable tips on completing your ‘Preferred Worker Program Quarterly Claim Cost Reimbursement Request Worksheet Oregon’ online

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Preferred Worker Program Oregon
Preferred employee
PWP program
Preferred worker program rules
Preferred Employee Program
Preferred workers
Preferred workers' comp

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