Ohio > Workers Comp > Employers
Application For Transitional Workgrant EZ BWC-2989 - Ohio
| Application For Transitional Workgrant EZ Form. This is a Ohio form and can be used in Employers Workers Comp . |
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Transitional W orkGRANT$-EZ For small business - Its easy Application instructions Mail your completed application to: Ohio Bureau of Workers Compensation Transitional WorkGRANT$-EZ Program 30 W. Spring St., 22nd floor Columbus, OH 43215-2256 Employer information Fax your application to (614) 621-1118. Application date _______ _______ /________ ________ /_______ ________ ________________________________________________________________________ ___________________________ Employer name (DBA) ________________________________________________________________________ ___________________________ Contact name BWC policy number ________________________________________________________________________ ___________________________ Employer address ______________________________________________________________( )_____________________________ Employer e-mail address Telephone number ________________________________________________________________________ ___________________________ City State ZIP code ________________________________________________________________________ ___________________________ Managed care organization name I have hired a BWC-accredited transitional work developer. ____________________________________________ Transitional work developer (Print name.) Type of industry: Manufacturing Service Office work Public employer Other__________________ Have you used these programs and services? Premium Discount Program + 10-Step Business Plan Drug-free workplace programs SafetyGRANT$ Division of Safety & Hygiene services Other _______________________________________________________________ ___________________ Indicate your organizations number of employees: _________________________________________________ __ (Include all permanent full-time, part-time and intermittent/seasonal e mployees.) Do you have an existing light duty/transitional work program? Yes No I request education on how to select a BWC-accredited transitional work developer. Yes No x ________________________________________________________________________ __________________________ Signature of designated employer representative Date signed American LegalNet, Inc. www.USCourtForms.comBWC-2989 (11/10/2003) TWG-EZ-104
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