Workers’ Compensation Division Preferred Worker Employment Purchase Agreement (Moving Assistance) 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; TTY (503) 947-7993. 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): Date worker started job: Job at the time of injury: Worker’s job title: The Workers’ Compensation Division (WCD) and worker agree to the following: 1) 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. 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 which items have been 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. 440-3293 (12/07/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 co. or truck rental address(es): $ $ $ $ Current address: Miles Mileage Rate New employer address: $ Address of lodging: Temporary lodging Days Lodging: Room tax: $ $ Per diem for food allowance Days Rate $ Landlord’s name, address, and phone: Rental allowance (Include rental agreement.) Rate $ First month’s rent Non-refundable deposits (if required) $ Total agreement amount: $ By my signature, I understand that knowingly misrepresenting information or otherwise falsely obtaining assistance under this agreement subjects me to sanctions 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: Certified true, accurate, correct, and an appropriate expenditure for this program. Program approval Date WCD reg. no. Fax to: 503-947-7581, or Send to: Preferred Worker Program, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 440-3293 (12/07/DCBS/WCD/WEB) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com