Oregon > Workers Comp > Preferred Worker Program
Preferred Worker Employment Purchase Agreement (Placement Assistance) 4875 - Oregon
| Preferred Worker Employment Purchase Agreement (Placement Assistance) Form. This is a Oregon form and can be used in Preferred Worker Program Workers Comp . |
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Preferred Worker Placement Assistance Agreement Workers' Compensation Division For help, contact the Preferred Worker Program in Salem, 503-947-7588; toll-free 800-445-3948; fax 503-947-7581. Employer Worker Legal name: Doing business as: Complete address: (Street/P.O. Box, city, state, ZIP) Name: Complete address: (Street/P.O. Box, city, state, ZIP) Phone: WCD no.: (from front of preferred worker card) Phone: Contact person(s): Federal tax ID no.: Date worker started job: Worker's 90th day on the job (date): Counselor/Contractor Name: Agency: Phone: Address: (Street/P.O. Box, city, state, ZIP) Agreement: The contractor is a representative of a public or private agency or is a certified vocational counselor. The contractor holds licenses or certificates required by law or rule to perform this service. The contractor understands this assistance may not be combined with vocational assistance under OAR 436-120. Description of assistance Charge Total: $ By my signature, I agree to provide WCD with a detailed bill for the above services after verifying that the worker has been employed with this employer for at least 90 days. I understand that the maximum amount allowed for placement help for this worker is $2,000, or the remaining balance if the worker has already used some of the benefit. Contractor signature Certification no. Date By my signature, I understand I am authorizing use of my benefits for placement services. Worker signature Date Fax to 503-947-7581 or mail to Preferred Worker Program, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 This agreement is not valid until signed by an authorized representative of WCD. WCD USE ONLY Data entry Program approval Start date: 440-4875 (2/12/DCBS/WCD/WEB) Date End date: American LegalNet, Inc. www.FormsWorkFlow.com
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