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Employer Incentive Contract BWC-2970 - Ohio

Employer Incentive Contract Form. This is a Ohio form and can be used in Medical Providers Workers Comp .
 Fillable pdf Last Modified 12/4/2008
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Employer Incentive Contract Instructions · Pleaseprintortype. · Makesuretoenterfourdigitsfortheyearinalldatefields. · Case managerfollowthedistributionlistatthebottom. Injuredworkername Claimnumber 1. Theemployeragreestoemploytheinjuredworkerasanemployeewithalltherights,privilegesandresponsibilitiesof allothersimilarlysituatedemployeeswithemploymentas . 2. Thisemploymentistobeginon___________________________.Thefullgrosswagetobepaidtotheinjured workeris$________________perhouror$________________perweek.Duetotheinjuredworker'sinitialadjustmentperiod,BWCagreestoreimbursetheemployerforaportionoftheinjuredworker'swagesaccordingto thedistributionbelow. Number of weeks From: From: From: From: From: From: Total weeks Period of reimbursement To: To: To: To: To: To: Total % paid Total % paid % Employer contribution Amount paid BWC contribution % Amount paid 3. Anytimetheinjuredworkerworksmorethan________hoursperdayor_______hoursperweek,theemployer willpaycompensationforsuchhours. 4. ReimbursementofincentivemoniescanonlyoccurwhenBWCreceivesdocumentationofgrosswages(i.e. signedpayrollrecords)paidtotheinjuredworkerforthecontractedreimbursementperiod. 5. TheemployerunderstandsthatBWC'sofferofreimbursementinthiscontract,fortheemploymentorre-employmentoftheinjuredworker,isadiscretionaryfunctionofBWC. 6. ThisagreementshallbeinfullforceandeffectuntilcanceledbyeithertheemployerorBWCwith10dayswrittennoticetoeachoftheotherpartiesorupontheterminationoftheinjuredworker'semployment. Warning:AnypersonwhoobtainscompensationfromBWCorself-insuringemployersbyknowinglymisrepresentingorconcealingfacts, makingfalsestatementsoracceptingcompensationtowhichhe/sheisnotentitled,issubjecttofelonycriminalprosecutionforfraud. Authorizedemployername Address Employerrepresentativesignature(Name&Title) Injuredworkersignature Vocationalrehabilitationcasemanagersignature City State 9-digitZIPCode Date Date Date Distribution: BWCclaimfile,injuredworker,injuredworkerrepresentative,employer,employerrepresentative BWC-2970(Rev.10/08/08) RH-19 American LegalNet, Inc. www.FormsWorkflow.com
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