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Claim Reserve Worksheet 2808 - Oregon

Claim Reserve Worksheet Form. This is a Oregon form and can be used in Self Insured Employer Workers Comp .
 Fillable pdf Last Modified 2/11/2009
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Claim Reserve Worksheet Workers' Compensation Division Self-insured employer: Worker's name: Date of injury: Average weekly wage at D/I: Valuation date: Jan. 1, SI employer notes: Sex: M/F Date of birth: Claim number: Total paid Indemnity TTD/TPD paid: Future TTD/TPD PPD awarded -- paid PPD awarded -- unpaid Estimated future PPD (percent scheduled/unscheduled): Outstanding reserves (# weeks) X (TTD rate): $0.00 (percent scheduled/unscheduled): Medical Medical paid: Future medical: (show burial allowance on reverse side only): (yrs.) X $ : $0.00 If applicable, life expectancy Vocational assistance Vocational assistance paid: Future vocational assistance: TTD while in ATP (weeks) X Other vocational assistance costs (TTD rate): $ $0.00 Other Litigation -- potential liability: PTD/fatal benefits (see reverse side for calculation of outstanding reserves) $0.00 Totals SIR HWR $ % Subtotals: $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Total paid, outstanding reserves Total incurred losses: Total paid + outstanding reserves = 440-2808 (8/07/DCBS/WCD/WEB) 2808 American LegalNet, Inc. www.FormsWorkflow.com PTD/Fatal Reserving Worksheet (complete both sides) PTD Benefits -- Complete PTD and Dependents sections PTD effective date: Future anticipated PTD benefits D.O.B. Workers Spouse Widow(er) Social Security offset effective date: Remaining years X X X Months 12 12 12 Monthly statutory rate X X X Outstanding reserves $0.00 $0.00 $0.00 # Months To age 65 X Monthly offset amount up to max. of stat. rate = $0.00 Burial allowance (in accordance with law in effect at date of injury) Fatal benefits -- Complete Fatal and Dependents sections Fatal benefits effective date: Future anticipated fatal benefits D.O.B. Widow(er) Widow(er) without Child (DOI eff. 9/20/85) Remaining years X X Months 12 12 Monthly statutory rate X X $0.00 $0.00 Dependents -- PTD or fatal D.O.B. Child #1 Child #2 Child #3 Child #4 Remaining months X X X X Monthly statutory rate $0.00 $0.00 $0.00 $0.00 $0.00 Total (carry forward to front of worksheet, "Other" section) 440-2808 (8/07/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com
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