Workers' Compensation Division Preferred Worker Wage Subsidy Agreement If you have questions or need more help, contact the Preferred Worker Program in Salem, 503-947-7588; toll-free 800-445-3948; fax 503-947-7581. Employer Worker New employer Legal name: Doing business as: Complete address: (Street/P.O. Box, City, State, ZIP) Employer at injury Name: Complete address: (Street/P.O. Box, City, State, ZIP) Phone: WCD no.: (see front of preferred worker card) Phone: Contact person(s): Federal tax ID no.: Date worker started job: Worker's job title: Job at the time of injury: Estimate of wage subsidy amount (Note: This is an estimate only. Reimbursement to the employer will be based on gross wages actually paid during this agreement period.): a) Estimated gross wages to be paid the worker in 183 calendar days. When estimating wages, include expected raises, holiday pay, paid leave, overtime, etc. ............................................................................................................... b) Line (a) divided by 2 equals the estimated total reimbursement..................................................... c) Date you prefer the wage subsidy to start: $ $ By our signatures, we agree with the conditions on page 2 of this form. Worker signature* *Not required if request is initiated by employer at injury Date Employer signature Date This agreement is not valid until signed by an authorized representative of WCD. WCD USE ONLY Wage subsidy effective dates: Start date: End date: Data entry Program approval Date 440-2190 (5/11/DCBS/WCD/WEB) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CONDITIONS OF THIS AGREEMENT The employer will: 1) Maintain Oregon workers' compensation insurance coverage as long as the employer is a subject employer as defined by ORS 656.023. 2) Employ the worker according to the same business practices, policies, and agreements affecting all other employees. 3) Get the worker's signature on requests not initiated by the employer at injury. 4) Submit a completed Wage Subsidy Reimbursement Request to the Workers' Compensation Division (WCD) to obtain reimbursement. All requests must be submitted within one year of the agreement end date or reimbursement will not be made. 5) Repay all costs WCD incurred under this agreement, including all legal costs and attorney fees, if WCD finds the employer falsely obtained re-employment assistance or if WCD subsequently prevails in any legal action against the employer arising out of this agreement. 6) If you are the employer at injury, submit a job offer letter signed by the worker with this request. (To see an example of the Preferred Worker Job Offer Letter, Form 4903, go to www.wcd.oregon.gov/policy/bulletins/forms.html.) The Workers' Compensation Division will: 1) Reimburse the employer 50 percent of the gross wages paid the worker for 183 days, as defined in OAR 436-110-0005. If the worker has an exceptional disability as defined in OAR 436-110-0005, the wage subsidy duration is 365 days with a reimbursement rate of 75 percent. 2) Reserve the right to visit the worksite and to inspect and copy employer records to verify employment of the worker and otherwise determine compliance with this agreement. 3) End this agreement at any time by written notice to the employer and the worker. After signing this agreement: Fax to 503-947-7581 or Mail to Preferred Worker Program, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 440-2190 (5/11/DCBS/WCD/WEB) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com