Preferred Worker Program Quarterly Claim Cost Reimbursement Request
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Preferred Worker Program Quarterly Claim Cost Reimbursement Request Form. This is a Oregon form and can be use in Preferred Worker Program Workers Comp.
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Tags: Preferred Worker Program Quarterly Claim Cost Reimbursement Request, 3014, Oregon Workers Comp, Preferred Worker Program
Preferred Worker Program
Quarterly Claim Cost Reimbursement Request
(Effective Dec. 1, 2007)
Quarter
Self-Insured Employer
To:
Insurance Company
Department of Consumer & Business Services
Workers’ Compensation Division, Compliance Section
Benefits and Certification Unit
350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405
I certify that:
1) The costs listed do not include incidental costs of claims administration. (Note: Incidental costs for claims administration on claim costs will be calculated and reimbursed by
the Workers’ Compensation Division in accordance with OAR 436-110-0330(1)(b) and (c).)
2) The claim costs reimbursed by the Preferred Worker Program are not and will not be included in the data that will affect employer rates and/or dividend eligibility.
3) The payments reported have been made in the amounts indicated and have not been previously requested. Reimbursement is requested in the amount of $0.00.
From: Insurance company
or self-insured
employer (and TPA
if applicable) name
and address:
All costs must indicate the quarter and year of actual payment.
Signed:
Date:
Name and title:
(Print or type)
Phone:
(Print or type)
City
State
Claim costs
Claim status
Preferred
Worker
no.*
Nondis. or
Disabling
N
D
ZIP
Insurer claim
no.
Claimant name(s)
(Alphabetical order,
last, first)
Date
of new
injury
Date of
hire for
this job**
Qtr/Yr
of
payment
Disability
benefits
Medical
benefits
Total
costs
WCD
use
only
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Totals from Page 1:
$0.00
$0.00
Totals from all additional pages:
Totals:
$0.00
$0.00
$0.00
$0.00
$0.00
*Preferred Worker no. is the same as the WCD file number of the qualifying claim.
**Required on first request.
440-3014 (12/07/DCBS/WCD/WEB)
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