Ohio > Workers Comp > Medical Providers

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
Get this form for FREE as a print-only pdf

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
Link/Embed this Document
URL
Embed


Popular Searches

  1. statement of claim
  2. garnishment
  3. adoption
  4. small claims
  5. contempt
  6. appearance
  7. Unlawful Detainer
  8. eviction
  9. small estate affidavit
  10. motion to vacate

Bookmark and Share