In observance of Thanksgiving, our office will be closed Thursday and Friday 11/26 and 11/27. Please click here to create a support ticket. Normal phone support will resume on Monday, November 30th at 7:00 AM PST.
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 .
 Fillable pdf Last Modified 9/7/2010
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.
Link/Embed this Document

Popular Searches

  1. divorce
  2. Guardianship
  3. affidavit of service
  4. answer
  5. power of attorney
  6. complaint
  8. answer to complaint
  9. default judgment
  10. child support

Bookmark and Share