Preferred Worker Moving 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.: Job at the time of injury: Date worker started new job: Worker’s job title: The Workers’ Compensation Division (WCD) and worker agree to the following: 1) The Workers’ Compensation Division reserves the right to: a) Visit the worksite and 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. 2) The worker will: a) Use an Authorization for Payment (AFP), when applicable, or send WCD a legible copy of an invoice or receipt indicating what was purchased. All reimbursement requests must be submitted within one year of the agreement end date. b) Purchase only those items and services listed in the approved Employment Purchase Agreement. c) Repay all costs incurred by WCD under this agreement, including all legal costs and attorney fees, if WCD finds the worker falsely obtained re-employment assistance or if WCD subsequently prevails in any legal action against the worker arising out of this agreement. After completing the back of this request, sign it, attach any required receipts, and: Fax to 503-947-7581 or Mail to Preferred Worker Program, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 440-3293 (5/11/DCBS/WCD/WEB) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Worker name: Description of Assistance Moving expense (Include copy of estimate.) Price Moving company or truck rental address(es): Rental allowance (Include copy of signed rental agreement.) Mileage $ $ $ $ Landlord’s name, address, and phone: First month’s rent Nonrefundable deposits (if required) $ $ WCD USE ONLY Current home address: Miles Rate New employer address: Temporary lodging $ Name and address of lodging: Days Rate Lodging: Room tax: $ $ Per diem for food allowance Days Rate $ Total agreement amount: $ By my signature, I understand that if I knowingly misrepresent information or otherwise falsely obtain assistance under this agreement, I can be sanctioned under OAR 436-110-0900. WCD assumes no liability for injuries or damages caused by any employment purchase. Worker signature Date This agreement is not valid until signed by an authorized representative of WCD. WCD USE ONLY Maximum approved under this agreement Effective date: Data entry $ End date: Program approval 440-3293 (5/11/DCBS/WCD/WEB) Date Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com