Preferred Worker Worksite Creation Agreement Workers’ Compensation Division 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 Employer at injury Name: Complete address: Legal name: (Street/P.O. Box, City, State, ZIP) Doing business as: Complete address: (Street/P.O. Box, City, State, ZIP) Phone: WCD no.: (from front of preferred worker card) Phone: Contact person(s): Job at the time of injury: Federal tax ID no.: Date worker started job: Worker’s job title: Vendor Description of proposed purchase Unit(s)/ amounts Unit price WCD use only Total price Total agreement amount: $ Page 1 440-4122 (5/11/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com CONDITIONS OF THIS AGREEMENT The worker and employer will hold harmless all public entities within the limitations of ORS 30.260 et seq. or Article XI, Sections 7 and 10 of the Oregon Constitution, the State of Oregon, the department, and its officers, agents, employees, and assignees, from any claims, suits, or actions of any nature resulting from or arising out of the activities of the worker or employer or their designees, agents, or employees under 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) 3) 4) Employ the worker according to the terms of the employer’s business practices, policies, and agreements affecting all other employees. Repay all costs incurred by the Workers’ Compensation Division (WCD) 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. If you are the employer at injury, submit a job offer letter signed by the worker with this request. (To see an example of Preferred Worker Job Offer Letter, Form 4903, go to www.wcd.oregon.gov/policy/bulletins/forms.html.) The worker will: 1) Follow the same business practices, policies, and agreements affecting all other employees of same employer. 2) Be subject to sanctions under OAR 436-110-0900 if the worker has knowingly misrepresented information or otherwise falsely obtained assistance under this agreement. The Workers’ Compensation Division reserves the right to: 1) Pay only for items purchased under this agreement. 2) 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. We certify that the worker needs the items listed in this agreement to perform the job for which the employer is hiring them. The items are not provided by the employer. We understand that these purchases will become the employer’s property. WCD is not responsible for injuries or damages caused by any worksite creation purchase. Worker signature* Date Employer signature Date *Not required if initiated by employer at injury Fax to 503-947-7581 or Mail to Preferred Worker Program, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 This agreement is not valid until signed by an authorized representative of WCD. WCD USE ONLY Maximum approved under this agreement Effective date: Program approval Data entry $ End date: Date Page 2 440-4122 (5/11/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com