Preferred Worker Employment Purchase Agreement (Placement Assistance)
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Preferred Worker Employment Purchase Agreement (Placement Assistance) Form. This is a Oregon form and can be use in Preferred Worker Program Workers Comp.
Loading PDF...
Tags: Preferred Worker Employment Purchase Agreement (Placement Assistance), 4875, Oregon Workers Comp, Preferred Worker Program
Preferred Worker
Placement Assistance 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
Legal name:
Name:
Doing business as:
Complete address:
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.:
Date worker started job:
Worker’s 90th day on the job (date):
Counselor/Contractor
Name:
Address:
Agency:
(Street/P.O.
Box, City, State,
ZIP)
Phone:
Agreement:
The contractor is a representative of a public or private agency or is a certified vocational counselor. The contractor
holds licenses or certificates required by law or rule to perform this service. The contractor will advise the Workers’
Compensation Division immediately if such license becomes invalid for any reason.
Description of assistance
Charge
Total: $
By my signature, I agree to provide WCD with a detailed bill for the above services after verifying that the worker has
been employed with this employer for at least 90 days. I understand that the maximum amount allowed for placement
help for this worker is $2,000, or the remaining balance if the worker has already used some of the benefit.
Contractor signature
Certification no.
Date
By my signature, I understand I am authorizing use of my benefits for placement services.
Worker signature
Date
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
Program approval
440-4875 (5/11/DCBS/WCD/WEB)
Data entry
Date
American LegalNet, Inc.
www.FormsWorkFlow.com
