Preferred Worker Employment Purchase Agreement Workers’ Compensation Division (Worksite Creation – Employer-at-Injury) If you have questions or need further assistance, please contact the Preferred Worker Program in Salem, 503-947-7588; toll-free 800-445-3948; fax 503-947-7581. Employer Worker Legal name: Name: Complete address: Doing business as: Complete address: (Street/P.O. Box, City, State, ZIP) (Street/P.O. Box, City, State, ZIP) Phone: Phone: WCD no.: (from front of Preferred Worker card) Contact person(s): Federal tax ID no.: Job at the time of injury: Date worker started job: Worker’s job title: The Workers’ Compensation Division (WCD) and employer agree to the following: 1) 2) The Workers’ Compensation Division will: a) 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. b) End this agreement at any time by written notice to the employer and the worker. The employer will: a) Maintain Oregon workers’ compensation insurance coverage as long as the employer is a subject employer as defined by ORS 656.023. b) Employ the worker according to the terms of the employer’s business practices, policies, and agreements affecting all other employees. c) Notify the program if the worker’s employment ends prior to completion of worksite creation. d) Use an Authorization for Payment (AFP), when applicable, or send WCD a legible copy of an invoice or receipt indicating which items have been purchased. All reimbursement requests must be submitted within one year of the agreement end date. e) 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, 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. f) Repay all costs incurred by WCD under this agreement if WCD finds the employer or worker obtained reemployment program assistance under false pretenses. Repayment may include, at WCD’s sole discretion, all legal costs and attorney fees should WCD prevail in legal action(s), and the return of worksite creation equipment provided by WCD. g) Agree the equipment described in this agreement will be purchased, installed, and available for the worker’s use as long as the worker is employed in this job. Page 1 440-4874 (1/10/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Worksite creation item(s) Unit(s)/ amounts Description of assistance Unit price Total price 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Total agreement amount: $ 0.00 Unless previously submitted, this request must be accompanied by a signed job offer showing the preferred worker agrees to accept the new or modified regular job. See attached letter template for necessary job details. This agreement is not valid until signed by an authorized representative of WCD. By my signature, I understand these purchases will become the employer’s property. WCD will not directly purchase or otherwise assume responsibility for these items and has no liability for injuries or damages caused by any worksite creation purchase. Employer signature Date Fax to: 503-947-7581, or Send to: Preferred Worker Program, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 WCD USE ONLY Maximum approved under this agreement Effective date: Data entry $ End date: Certified true, accurate, correct, and an appropriate expenditure for this program. Program approval Date Page 2 440-4874 (1/10/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Preferred Worker Job Offer Letter Employer at injury: Date: Preferred Worker Name: Address: City, State, ZIP: Dear : Since you are unable to return to your regular job at injury, we have developed this job within your physical restrictions. Job title: Start date: Wages: Hours: Location: Description of job duties (or attach job description): Sincerely, I have read and understand this job offer. I accept this job as offered. Yes Employee signature No Date American LegalNet, Inc. www.FormsWorkFlow.com