(1) If a claim disposition agreement involves
more than one claim, the disposition shall contain all of the information
required by this rule for each claim including a separate first page of the
claim disposition agreement as set forth in section (3) of this rule.
(2) The insurer/self-insured employer shall
provide the claimant information explaining claim dispositions in a separate
enclosure accompanying the proposed claim disposition agreement. The Board
shall prescribe by a bulletin the specific form and format for the enclosure.
If the claimant does not read or comprehend English, or is otherwise unable to
understand written language, the insurer/self-insured employer shall provide
this information in a language or other manner which ensures the worker
understands the meaning of the disposition.
(3) The first page of the claim disposition
agreement shall include, but not be limited to, the following information:
(a) The worker's name;
(b) The case number assigned to the claim by
the Board, if any;
(c) The
insurer's/self-insured employer's claim number;
(d) The date of the compensable injury or
disease;
(e) The file number
assigned to the claim by the Workers' Compensation Division, if
known;
(f) The name of the
insurer/self-insured employer;
(g)
Specific identification of all benefits, rights and insurer/self-insured
employer obligations under Workers' Compensation Law which are released by the
agreement;
(h) The total attorney
fee, if any, to be paid to claimant's attorney;
(i) The total amount (excluding attorney fee)
to be paid to the claimant; and
(j)
A statement indicating whether or not the parties are waiving the "30-day"
approval period of ORS
656.236(1)(a)(C)
as permitted by 656.236(1)(b).
(4) The claim disposition
agreement shall also contain, but not be limited to, the following:
(a) Identification of the accepted conditions
that are the subject of the disposition;
(b) The date of the first claim closure, if
any;
(c) The amount of any
permanent disability award(s), if any;
(d) Whether the worker has ever been able to
return to the work force following the industrial injury or occupational
disease;
(e) The worker's age,
highest education level, and the extent of vocational training (or in the event
that the worker is deceased, the age, highest education level, and the extent
of vocational training of the worker's beneficiaries);
(f) A list of occupations that the worker has
performed (or in the event that the worker is deceased, a list of occupations
that each of the deceased worker's beneficiaries has performed);
(g) That the worker has been provided the
informational enclosure prescribed by bulletin pursuant to section (2) of this
rule (attachment of the informational enclosure to the parties' claim
disposition agreement is not required, unless the enclosure is expressly
incorporated into the agreement); and
(h) The following notice in prominent or bold
face type, which shall either be included in the claim disposition agreement or
incorporated by reference into the agreement:
"NOTICE TO CLAIMANT: UNLESS YOU ARE REPRESENTED BY AN ATTORNEY
AND YOUR CLAIM DISPOSITION AGREEMENT INCLUDES A PROVISION WHICH WAIVES THE
30-DAY "COOLING OFF" PERIOD, YOU WILL RECEIVE A NOTICE FROM THE WORKERS'
COMPENSATION BOARD OR THE ADMINISTRATIVE LAW JUDGE WHO MEDIATED THE AGREEMENT
TELLING YOU THE DATE THIS AGREEMENT WAS RECEIVED BY THEM FOR APPROVAL. YOU HAVE
30 DAYS FROM THE DATE THE BOARD OR THE ADMINISTRATIVE LAW JUDGE WHO MEDIATED
THE AGREEMENT RECEIVES THE AGREEMENT TO REJECT THE AGREEMENT, BY TELLING THE
BOARD OR THE ADMINISTRATIVE LAW JUDGE WHO MEDIATED THE AGREEMENT IN WRITING.
DURING THE 30 DAYS ALL OTHER PROCEEDINGS AND PAYMENT OBLIGATIONS OF THE
INSURER/SELF-INSURED EMPLOYER, EXCEPT FOR MEDICAL SERVICES, ARE STAYED ON YOUR
CLAIM. IF YOU DO NOT HAVE AN ATTORNEY, YOU MAY DISCUSS THIS AGREEMENT WITH THE
BOARD IN PERSON WITHOUT FEE OR CHARGE. TO CONTACT THE BOARD, WRITE OR CALL:
WORKERS' COMPENSATION BOARD, 2601 25TH STREET SE, SUITE 150, SALEM, OREGON
97302-1280, TELEPHONE: (503) 378-3308, TOLL-FREE AT 1-877-311-8061, 8:00 TO
5:00, MONDAY THROUGH FRIDAY. "YOU MAY ALSO DISCUSS THIS AGREEMENT WITH THE
OMBUDSMAN FOR INJURED WORKERS, WITHOUT FEE OR CHARGE. TO CONTACT THE OMBUDSMAN,
WRITE OR CALL: OMBUDSMAN FOR INJURED WORKERS, LABOR & INDUSTRIES BUILDING,
350 WINTER STREET NE, SALEM, OR 97310, TELEPHONE: TOLL-FREE AT 1-800-927-1271,
8:00 TO 5:00, MONDAY THROUGH FRIDAY. "YOU MAY ALSO CALL THE WORKERS'
COMPENSATION DIVISION'S INJURED WORKER HOTLINE, TOLL-FREE AT
1-800-452-0288."
Notes
Or. Admin. R.
438-009-0022
WCB 2-1995, f. 11-13-96,
cert. ef. 1-1-96; WCB 1-1999, f. 8-24-99, cert. ef. 11-1-99; WCB 2-2007, f.
12-11-07, cert. ef. 1-1-08; WCB 1-2012, f. 8-22-12, cert. ef.
11-1-12
Stat. Auth: ORS
656.726(5)
Stats Implemented: ORS
656.236
