Oregon > Workers Comp > Preferred Worker Program
Preferred Worker Program Quarterly Claim Cost Reimbursement Request 3014 - Oregon
| Preferred Worker Program Quarterly Claim Cost Reimbursement Request Form. This is a Oregon form and can be used in Preferred Worker Program Workers Comp . |
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Preferred Worker Program Quarterly Claim Cost Reimbursement Request (Effective Dec. 1, 2007) Quarter Self-Insured Employer To: Insurance Company Department of Consumer & Business Services Workers' Compensation Division, Compliance Section Benefits and Certification Unit 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 I certify that: 1) The costs listed do not include incidental costs of claims administration. (Note: Incidental costs for claims administration on claim costs will be calculated and reimbursed by the Workers' Compensation Division in accordance with OAR 436-110-0330(1)(b) and (c).) 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 and/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 $0.00. All costs must indicate the quarter and year of actual payment. Signed: Name and title: Phone: Claim status Date: (Print or type) (Print or type) From: Insurance company or self-insured employer (and TPA if applicable) name and address: City State ZIP Claim costs Insurer claim no. Claimant name(s) (Alphabetical order, last, first) Date of new injury Date of hire for this job** Qtr/Yr of payment Disability benefits Medical benefits Total costs $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Preferred Worker no.* Nondis. or Disabling N D WCD use only Totals from Page 1: Totals from all additional pages: Totals: $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 *Preferred Worker no. is the same as the WCD file number of the qualifying claim. **Required on first request. 440-3014 (12/07/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com
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