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Claim Reserve Worksheet Form. This is a Oregon form and can be use in Self Insured Employer Workers Comp.
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Tags: Claim Reserve Worksheet, 2808, Oregon Workers Comp, Self Insured Employer
Claim Reserve Worksheet
Workers’ Compensation Division
Self-insured employer:
Worker’s name:
Sex: M/F
Date of injury:
Date of birth:
Claim number:
Average weekly wage at D/I:
SI employer notes:
Valuation date: Jan. 1,
Total
paid
Outstanding
reserves
Indemnity
TTD/TPD paid:
Future TTD/TPD
(# weeks) X
PPD awarded — paid
$0.00
(TTD rate):
(percent scheduled/unscheduled):
PPD awarded — unpaid
Estimated future PPD
(percent scheduled/unscheduled):
Medical
Medical paid:
Future medical:
(show burial allowance on reverse side only):
If applicable, life expectancy
(yrs.) X
$0.00
:
$
Vocational assistance
Vocational assistance paid:
Future vocational assistance:
TTD while in ATP (weeks) X
(TTD rate):
$0.00
$
Other vocational assistance costs
Other
Litigation — potential liability:
$0.00
PTD/fatal benefits (see reverse side for calculation of outstanding reserves)
Totals
SIR
HWR
$
Subtotals:
%
Total paid, outstanding reserves
Total incurred losses: Total paid + outstanding reserves =
440-2808 (1/09/DCBS/WCD/WEB)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
2808
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PTD/Fatal Reserving Worksheet
(complete both sides)
PTD Benefits — Complete PTD and Dependents sections
PTD effective date:
Future anticipated PTD benefits
Remaining
years
D.O.B.
Monthly
statutory rate
Months
Outstanding
reserves
Workers
X
12
X
$0.00
Spouse
X
12
X
$0.00
Widow(er)
X
12
X
$0.00
Social Security offset effective date:
# Months to worker’s full
retirement age
Monthly offset amount
up to max. of stat. rate
$0.00
=
X
Burial allowance (in accordance with law in effect at date of injury)
Fatal benefits — Complete Fatal and Dependents sections
Fatal benefits effective date:
Future anticipated fatal benefits
Remaining
years
D.O.B.
Monthly
statutory rate
Months
X
12
X
$0.00
X
Widow(er)
Widow(er) without child
(DOI eff. 9/20/85)
12
X
$0.00
Dependents — PTD or fatal
Remaining
months
D.O.B.
Monthly
statutory rate
Child #1
X
$0.00
Child #2
X
$0.00
Child #3
X
$0.00
Child #4
X
$0.00
Total (carry forward to front of worksheet, “Other” section)
$0.00
440-2808 (1/09/DCBS/WCD/WEB)
American LegalNet, Inc.
www.FormsWorkflow.com
