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Preferred Worker Wage Subsidy Agreement (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 Wage Subsidy Agreement (Employer At Injury), 2970, Oregon Workers Comp, Preferred Worker Program
Preferred Worker
Wage Subsidy Agreement
Workers’ Compensation Division
(Employer at Injury)
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):
Federal tax ID no.:
Job at the time of injury:
Date worker started job:
Worker’s job title:
The Workers’ Compensation Division (WCD) and the employer agree to the following:
1) The Workers’ Compensation Division will:
a) Reimburse the employer 50 percent of the wages paid the worker for 183 days, as defined in OAR 436-1100005. If the worker has an exceptional disability as defined in OAR 436-110-0005, the wage subsidy duration is
365 days with a reimbursement rate of 75 percent.
b) 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.
c) End this agreement at any time by written notice to the employer and the worker.
3) The employer will:
a) Maintain Oregon workers’ compensation insurance coverage as long as the employer is a subject employer as
defined by ORS 656.023.
b) Employ the worker according to the same business practices, policies, and agreements affecting all other
employees.
c) Submit a completed Wage Subsidy Reimbursement Request to WCD to obtain reimbursement. All requests
must be submitted within one year of the agreement end date or reimbursement will not be made.
d) Repay all costs incurred by WCD under this agreement, including all legal costs and attorney fees, if WCD finds
the employer falsely obtained reemployment assistance, or if WCD subsequently prevails in any legal action
against the employer arising out of this agreement.
440-2970 (12/07/DCBS/WCD/WEB)
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4) Estimate of wage subsidy amount (Note: This is an estimate only. Reimbursement to the employer will be 50
percent of the gross taxable wages actually paid during this agreement period.):
a) Estimated gross taxable wages to be paid the worker in six months (183 days).
When estimating wages, be sure to include expected raises, holiday pay,
paid leave, overtime ........................................................................................................................
$
b) Line (a) divided by 2 equals the estimated total reimbursement.....................................................
$
c) Date you prefer the wage subsidy to start:
This agreement is not valid until signed by an authorized representative of WCD.
To the best of my knowledge, this job is within the worker’s injury-caused restrictions. I understand the division
assumes no liability for payment of wages. By signing this agreement, I am affirming I have authority to act for and
on behalf of the employer.
Employer signature
Date
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
Wage subsidy effective dates: Start date:
Data entry
End date:
Certified true, accurate, correct, and an appropriate expenditure for this program.
Program approval
440-2970 (12/07/DCBS/WCD/WEB)
Date
WCD Reg. No.
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