Ohio > Workers Comp > Medical Providers
Loan Release Agreement For Tools And Equipment BWC-2957 - Ohio
| Loan Release Agreement For Tools And Equipment Form. This is a Ohio form and can be used in Medical Providers Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Loan/Release Agreement for Tools and Equipment Instructions · Pleaseprintortype. · MCO rep:Followthedistributionlistatthebottom. Injuredworkername Address City State Claimnumber Nine-digitZIPcode Description of tool or equipment QTY Cost Date item loaned Date item returned Date item released A B C D E F G I,theinjuredworker,understandthatBWCisloaningtheitemsabovetome,andtheywillremainthepropertyofBWCuntilreleasedtomeinwriting.I understandBWCmayrequiremetoreplacelostordamageditems,unlessthedamageisduetonormalwearandtear. TheMCOrepresentativewillcompletethisRelease statement,andtransfertheseitemstomeafter90daysofemployment.Iagreetoreturntheseitems totheMCOrepresentativeifthisemploymentisnotmaintainedforninety90days. Loan agreement Ihavereceivedtheabovedescribeditem(s)frommyMCOrepresentative. Injuredworkersignature AuthorizedMCOrepresentativesignature Date Date Return statement Theabovedescribeditem(s)willbereturnedtoBWCbymyMCOrepresentative. Injuredworkersignature AuthorizedMCOrepresentativesignature MCO Release statement Theabovedescribeditem(s)asindicatedbymysignatureandtoday'sdatewerereleasedtotheinjuredworkerbecauseIdeterminedtheitem(s)would benecessarytobeusedinhis/heremployment.Theinjuredworkerhasremainedemployed90daysafterreturningtoworkasaresultofarehabplan. AuthorizedMCOrepresentativesignature Date Distribution: BWC-2957(Rev.10/30/2009) RH-7 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
