440-2360 (7/18/DCBS/WCD/WEB) Employer-at-Injury Program (EAIP) Reimbursement Request Form (See form instructions on reverse side) WCD use only (check one) Initial request Correction Additional request Amended Worker information (1) Worker name: ( 7 ) Insurer claim no.: (2) SSN: ( 8 ) Accepted, date: (3) Date of birth: Denied, date: Deferred (4) Date of injury: (9) Disabling Nondisabling (5) WCD file no.: (10) Employer: (6) Address: (1 1 ) P olicy no. : City/state: ZIP: (12) WCD employer no.: EAIP information Concurrent injuries (OAR 436-105-0530) EAIP period: S tart date: End date: EAIP period interrupts EAIP for claim no . : Wage subsidy information Wage subsidy period: Start date: End date: EAIP period interrupted by EAIP for Reimburseme nt requested for transitional work days. claim no.: Purchase information Interruption start date: (a) EAIP purchases (tuition, books and fees, tools, equipment, and clothing) or Interrup tion end date: (b) worksite modification Type (a) or (b) Purchase date Itemized list of purchases Item cost Attach a separate list in same format, if necessary. Total request $ Summary (1) Total wages paid: $ x .45 $ (2) EAIP purchases ( complete above) ................................ ................................ ......... Total reimbursement: $ (3) Worksite modification ( complete above) ................................ ............................. Total reimbursement: $ (4) Administrative cost (flat rate of $120) r eimbursed o n initial request only: ................................ ............. $ Total reimbursement requested: $ Certifications and reimbursement information: I certify either that I am an insurer, self-insured employer, or service company or that the insurer, self-insured employer, or service company 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 wi th OAR 436 - 105. Insurance company/self - insured employer: Service company (if applicable): Send reimbursement to this address: City/state: ZIP: Insurer representative name (please print or type): Signa ture: Phone: Email: Date: Send to: Workers222 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 (7/18/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 .) Cor rection: Check this box if correcting a form returned by the division for being incomplete or containing an error. Additional request: Check this box if there was a prior approved EAIP request for this claim within the same EAIP period . ( T here is no admin istrative cost allowed on additional requests . ) Amended: Check this box if you ar e amend ing a previously processed request. Worker information (1) Worker name: Enter the worker222s legal name at the time of injury. (2) SSN: Enter the worker222s complete Social S ecurity number. (3) D ate of birth : Enter the worker222s date of birth. (4 ) Date of injury : Enter the date of injury provided by the insurer on the 801/1502/Notice of Acceptance /Denial . ( 5 ) WCD file no.: Enter t he file number provided by the Worker s222 Compensation Division. (Leave blank if unknown . ) (6 ) Address: Enter the worker222s current address , including city, state, and ZIP code. (7 ) Insurer claim no.: Enter the claim number the insurer assigned to the injured worker222s claim. (If the insurer ha s changed a previous claim number, provide both and write 223New224 in front of the new claim number . ) (8 ) Accepted: If the claim is accepted, check this box and enter the date it was accepted as stated in the Notice of Acceptance. Denied: If the cla im is denied, check this box and enter the date it was denied as stated in the Notice of Denial. Deferred: Check this box if the claim has not been accepted or denied . R eimbursement may be requested up to but not after the denial date. (9 ) Disabling: Ch eck this box if this claim is disabling. Nondisabling: Check this box if this claim is nondisabling. Note: A 223disabling224 or 223 nondisabling224 status must be designated on both accepted and denied claims. (10 ) Employer: Enter the legal name of the employer at the time of injury or aggravation . (1 1 ) Policy no.: Enter the policy number provided by the insurer. (1 2 ) WCD employer no.: Enter the WCD number assigned to the employer . You can look up the WCD employer number at http://www4.cbs.state.or.us/ex/wcd/employer/ . If you cannot locate the number, call WCD at 503-947-7814 or email wcd.employerinfo@oregon.gov . EAIP information EAIP period s tart date: Enter the date the worker wa s released to modified work. EAIP period e nd date: Enter the date the claim closes or the worker is no longer eligible under OAR 436 - 105 - 0512. Concurrent injuries: Enter the other claim number that is affected by this claim222s Employer - at - Injury Program . Wage subsidy information Wage subsidy period start date: Enter the date the worker return ed to modified work . Wage subsidy period end date: Enter the date the worker ends transitional work. Reimbursement request e d 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) EAIP purchase (tuition, books and fees, tools, equipment, and clothing) or (b) Worksite modification. Summary (1) Enter the total wages paid and multiply x .45. (2 ) EAIP purchases/total reimbursement: Enter the total of (a) purchases from the itemized list, if applicable. (3 ) Worksite modification/total reimbursement: Enter the total of (b) purchases from the itemized list, if applicable. (4 ) 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 workers222 compensation claim at the time of injury . Service compa n y: Enter the service company , 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 f orm and sign the form . Phone number , e mail , and date : Enter the representative222s pho ne number, e mail address , and the date the form is mailed . Questions If you have reimbursement questions, call 503 - 947 - 7751 . If you have program questions , call 800 - 445 - 3948 (toll - free). American LegalNet, Inc. www.FormsWorkFlow.com