State Fund Employers Agreement To Accept Claim Assignment {BWC-1395}

State Fund Employer's Agreement to Accept Claim Assignment Instructions Complete this form when you are accepting assignment of a claim that BWC or another party erroneously assigned to another statefund employer. Date of injury Claim number Injured worker name Employer name Employer policy number Address City Employer phone number State ZIP code By signing this form, I acknowledge the following: I accept reassignment of the above-listed claim to my policy number. I agree to accept responsibility for the above-listed claim and the risk associated with any and all medical benefits and compensation previously paid or to be paid in the claim. I understand that BWC may, upon execution of this agreement, assign the claim to my company and policy number. Please include comments or exceptions below. Comments I certify the information provided is correct to the best of my knowledge. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact, or any other act of fraud is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment or both. Signature Title Date signed BWC-1395 C-263 American LegalNet, Inc. www.FormsWorkFlow.com