Ohio > Workers Comp > Employers
Wage Agreement BWC-1123 - Ohio
| Wage Agreement Form. This is a Ohio form and can be used in Employers Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Wage Agreement Instructions · SubmitthisformpriortopaymentbyBWCtoavoidapossibleoverpaymenttotheemployee. · Employerandemployeemustsignanddatethisagreement. · MailorfaxthiscompletedformtoyourlocalBWCserviceoffice. Employeename Dateofinjury Claimnumber Employername Telephonenumber () The employer has paid or agrees to pay an advancement of wages to the above employee untilthepaymentoftemporarytotalcompensationbegins.Advancementofwagesbeginon ___________________to____________________atarateof$____________perweekforatotalof $______________. Bysigningthisagreement,theemployerandemployeehaveenteredintoawageagreementto reimbursetheemployeratleasttotheextentofanycompensationpaidtotheemployeeover thesameperiodinwhichtheemployerpaidwagesormadeadvancements. ThisagreementshallgrantBWCtheauthoritytosendwarrantsfortemporarytotalcompensation totheemployeeincareoftheemployerfornomorethanthefirst12weeksofcompensation closelyfollowingthedateofinjury. hewarrantsmustbeendorsedpersonallybytheemployee. T BWCmaypayawageagreementbeyond12weeksinvolvingspecialcircumstances. Employeesignature Date Employersignatureandtitle Date BWC-1123(10/17/2011) C-18 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
