Preferred Worker Program - Quarterly Claim Cost Reimbursement Request - Oregon 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the self-insured employer's name and address at the top of the form. This information is crucial for identifying who is submitting the reimbursement request.
3. Fill in the year and quarter for which you are requesting reimbursement. Ensure that these dates correspond to the actual payment period.
4. In the certification section, confirm that all costs listed are reimbursable under Oregon Administrative Rule 436-110-0330. You will need to sign and print your name and title, along with your phone number.
5. List all claim costs in the designated fields, including preferred worker number, insurer claim number, claimant names, dates of new injury, and hire date for this job if it's your first request.
6. Finally, calculate and enter total costs from all pages at the bottom of the form. Make sure to double-check your entries for accuracy before submission.

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