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Transitional WorkGrant EZ Reimbursement Request Additional Services TWG-EZ-111 - Ohio
| Transitional WorkGrant EZ Reimbursement Request Additional Services Form. This is a Ohio form and can be used in Employers Workers Comp . |
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Transitional WorkGRANT$-EZ For small business - Its easy Reimbursement Request- Additional services Employer information ________________________________________________________________________ __________________________ Employer name (DBA) ________________________________________________________________________ ___________________________ Contact name Title BWC policy number ________________________________________________________________________ ___________________________ Employer address _____________________________________( )___________________ ___( )________________________ Employer e-mail address Fax number Telephone number ________________________________________________________________________ ___________________________ City State ZIP code ________________________________________________________________________ ___________________________ Managed care organization (MCO) Number of employees To the best of my knowledge, the information submitted on this form is co rrect. ________________________________________________________________________ ___________________________ Authorized employer signature and title date signed Please complete and total BWCs accredited transitional work developers invoice amounts for section VII. Fax your application to (614) 621-1118. First claim $ _____________ E-mail: TWGFeed@bwc.state.oh.us Program improvement $ _____________ Mail your completed application to: Job analyses $ _____________ Ohio Bureau of Workers Compensation Transitional WorkGRANT$-EZ Program Training $ _____________ 30 W. Spring St., 22nd floor Total $ _____________ Columbus, OH 43215-2256 Transitional WorkGRANT$-EZ Instructions: Please type or print clearly. When you submit for reimbursement of additional services, include the Transitional WorkGRANT$ - EZ Reimbursement Request (TWG-EZ-100) with Section VII completed, and the supporting materials , including BWC-accredited transitional work developers invoice and the Transitional WorkGRANT$ - EZ Agreement (TWG-EZ-110). BWCs Transitional WorkGRANT$ review team will evaluate the application. Thank you for investing in your company s most valuable resource - your workers. Section VII Additional services Services must be performed by a BWC-accredited transitional work develo per. Please indicate the services your company received: Assistance with employers first claim in the transitional work program; Program improvement; Update job analyses or additional job analyses; Training for employers new workers compensation manager. ________________________________________________________________________ _________________________________________________________ Transitional work developer (print name) BWC-accreditation number and e-mail address ________________________________________________________________________ _________________________________________________________ Signature date signed American LegalNet, Inc. www.USCourtForms.com(10/27/2003) TWG-EZ-100
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