Transitional WorkGRANT$-EZ For small business - It’s easy Reimbursement Request-Additional services Employer information __________________________________________________________________________________________________ Employer name (DBA) ___________________________________________________________________________________________________ Contact name Title BWC policy number ___________________________________________________________________________________________________ Employer address _____________________________________( )______________________( )________________________ Employer e-mail address Fax number Telephone number ___________________________________________________________________________________________________ City State ZIP code ___________________________________________________________________________________________________ Managed care organization (MCO) Number of employees To the best of my knowledge, the information submitted on this form is correct. ___________________________________________________________________________________________________ Authorized employer signature and title date signed Fax your application to (614) 621-1118. E-mail: TWGFeed@bwc.state.oh.us Mail your completed application to: Ohio Bureau of Workers’ Compensation Transitional WorkGRANT$-EZ Program 30 W. Spring St., 22nd floor Columbus, OH 43215-2256 Please complete and total BWC’s accredited transitional work developer’s invoice amounts for section VII. First claim $ _____________ Program improvement $ _____________ Job analyses $ _____________ Training $ _____________ Total $ _____________ 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 developer’s invoice and the Transitional WorkGRANT$ - EZ Agreement (TWG-EZ-110). BWC’s 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 developer. Please indicate the services your company received: J J J J Assistance with employer’s first claim in the transitional work program; Program improvement; Update job analyses or additional job analyses; Training for employer’s new worker’s 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