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Preferred Worker Program Obtained Employment Purchase Agreement (For Employer At Injury) Form. This is a Oregon form and can be use in Preferred Worker Program Workers Comp.
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Tags: Preferred Worker Program Obtained Employment Purchase Agreement (For Employer At Injury), 2971, Oregon Workers Comp, Preferred Worker Program
Workers’ Compensation Division
Preferred Worker
Employment Purchase Agreement
(Employer at Injury)
If you have questions or need assistance completing this agreement, 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:
Date of injury:
Contact person(s):
Job at the time of injury:
Federal tax ID no.:
Date the worker started this job:
Worker’s job title:
The Workers’ Compensation Division (WCD) and employer 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 employer at injury will:
a) Maintain Oregon workers’ compensation insurance coverage as long as the employer is a subject employer as
defined by ORS 656.023.
b) 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.
c) Purchase only those items and services listed in this approved Employment Purchase Agreement.
d) Be subject to sanctions under OAR 436-110-0900 if the employer at injury has knowingly misrepresented
information or otherwise falsely obtained assistance under this agreement.
440-2971 (12/07/DCBS/WCD/WEB)
Page 1
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Worker name:
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
0.00
Total, page 2: $
Total, page 3: $
0.00
Total agreement amount: $
0.00
This agreement is not valid until signed by an authorized representative of WCD.
I hereby certify that the items listed in this agreement are required for the worker to perform the job for which the
worker is being employed. I understand that these employment purchases will become the worker’s property, and
that WCD has no liability for injuries or damages caused by any employment purchase. By signing this agreement, I
am affirming I have authority to act for and on behalf of the employer.
Employer signature
Date
Employer title
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
$
Worker’s WCD no.
End date:
Certified true, accurate, correct, and an appropriate expenditure for this program.
Program approval
440-2971 (12/07/DCBS/WCD/WEB)
Date
Employer’s WCD reg. no.
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Worker name:
(Additional items)
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
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total, page 3: $
Employer signature
440-2971 (12/07/DCBS/WCD/WEB)
0.00
Date
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