Oregon > Workers Comp > Employer At Injury Program
Employer-At-Injury Program (EAIP) Reimbursement Request Form 2360 - Oregon
| Employer-At-Injury Program (EAIP) Reimbursement Request Form Form. This is a Oregon form and can be used in Employer At Injury Program Workers Comp . |
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WCD use only Employer-at-Injury Program (EAIP) Reimbursement Request Form Workers' Compensation Division (See form instructions on reverse side) (check one) Initial request Additional request Amended Worker information (1) (2) (3) (4) (5) Worker name: SSN: DOI: WCD file no.: Address: City/state: ZIP: (8) (9) (10) (11) (6) (7) Insurer claim no.: Accepted, date: Denied, date: Disabling Employer: Policy no.: Employer WCD reg. no.: Nondisabling Deferred EAIP information EAIP period: Start date: End date: Wage subsidy information Wage subsidy period: Start date: Reimbursement requested for End date: transitional work days. or (b) worksite modification Item cost Purchase information (a) EAIP purchases (tuition, books and fees, tools, equipment, and clothing) Type (a) or (b) Purchase date Itemized list of purchases Attach a separate list in same format, if necessary. Total request Total wages paid: $ $ $ $ $ $ $ Summary (1) (2) (3) ÷2= EAIP purchases (complete above) .........................................................................Total reimbursement: Worksite modification (complete above) ..............................................................Total reimbursement: Administrative cost (flat rate of $120) reimbursed on initial request only: ............................................. Total reimbursement requested: Certifications and reimbursement information: I certify either that I am an insurer, self-insured employer, or third-party administrator or that the insurer, self-insured employer, or third-party administrator 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/TPA (if applicable): Send reimbursement to this address: Insurer representative name (please print or type): Phone: Send to: E-mail: City/state: ZIP: Signature: Date: Workers' Compensation Division, Performance Section, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 Or fax to 503-947-7725 American LegalNet, Inc. www.FormsWorkFlow.com 440-2360 (10/12/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.) 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 prior request. Worker information (1) (2) (3) (4) (5) (6) (7) Worker name: Enter the worker's legal name at the time of injury. SSN: Enter the worker's complete Social Security number. DOI: Enter the date of injury provided by the insurer on the 801/1502/Notice of Acceptance/Denial. WCD file no.: Enter the file number provided by the Workers' Compensation Division. (Leave blank if unknown.) Address: Enter the worker's current address, including city, state, and ZIP code. Insurer claim no.: Enter the claim number assigned to the injured worker's claim by the insurer. (If the insurer has changed a previous claim number, provide both and write "New" in front of the new claim number.) Accepted: If the claim is accepted, check this box and enter the date the claim was accepted as stated in the Notice of Acceptance. Denied: If the claim is denied, check this box and enter the date the claim 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. Disabling: Check this box if the insurer accepted this claim as disabling. Nondisabling: Check this box if the insurer accepted this claim as nondisabling. Employer: Enter the legal name of the employer at the time of injury or aggravation. Policy no.: Enter the policy number provided by the insurer. Employer WCD registration no.: Enter the number assigned to the employer by WCD. You can look up the WCD registration number at http://www4.cbs.state.or.us/ex/wcd/employer/. If you are unable to locate the number, call WCD for assistance, 503-947-7814, or e-mail wcd.employerinfo@state.or.us. EAIP period start date: Enter the date the worker is 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. (8) (9) (10) (11) EAIP information Wage subsidy information Wage subsidy period start date: Enter the date the worker returns 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) Worksite modification or (b) EAIP purchase (tuition, books and fees, tools, equipment, and clothing). Summary (1) (2) (3) EAIP purchases/total reimbursement: Enter the total of (a) purchases from the itemized list, if applicable. Worksite modification/total reimbursement: Enter the total of (b) purchases from the itemized list, if applicable. 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/TPA: Enter the third-party administrator, 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, e-mail, and date: Enter the representative's current phone number, e-mail address, and the date the form is mailed. Questions If you have reimbursement questions, call 503-947-7591. If you have program questions, call 800-445-3948 (toll-free). 440-2360 (10/12/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com
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