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Wage Agreement BWC-1123 - Ohio

Wage Agreement Form. This is a Ohio form and can be used in Employers Workers Comp .
 Fillable pdf Last Modified 1/30/2012
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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
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