Free Cost Form - Oregon

"Cost Bill" Form (ORS 656.386(2); OAR 438-015-0019)
To: (Insurer, Self-Insured Employer, Claim Administrator) Claimant: WCB Case No: Claim No: Date of Injury: Hearing Date: ALJ/Board/Court Order Date: EXPENSES AND COSTS (Itemized) Payee Date of Service Description Amount

Total $ I hereby confirm that the above expenses and costs were incurred in the litigation of the denied claim(s) involving the above-referenced claimant.

(Claimant or Claimant's Attorney)

(Date)

(Address) (Phone)