Waiver of Workers' Compensation Benefits for Recreational or Fitness Activities Instructions · Completethisformtowaiveworkers'compensationcoverageforvoluntaryparticipationinemployer-sponsoredrecreationalactivitiesorfitness programs. · Inthespaceprovided,listallemployer-sponsoredrecreationalactivitiesandfitnessprogramsforwhichtheemployeewishestowaiveworkers' compensationcoverage.Makealinethroughanyblankspaces. · Theemployeemust signanddatethisformtoacknowledgeagreement. · Theemployershallretaintheoriginalforhisorherfilesandprovideacopytotheemployee. · TheemployershouldsubmitacopytoBWConly when an employee files a claimforaninjuryoroccupationaldiseasesustainedintheemployer-sponsoredrecreationalactivityorfitnessprogram.Forfurtherinformationcall1-800-OHIOBWC(1-800-644-6292). Employeename(pleaseprintortype) Employername Date Risknumber PursuanttoSection4123.01(C)(3)oftheOhioRevisedCode(ORC),theemployerandemployee shalllistthoseemployer-sponsoredrecreationalactivitiesandfitnessprogramsforwhichtheemployee wishestowaiveallrightstocompensationandbenefitsunderChapter4123oftheORC.Thewaivermust besignedanddatedpriortothedateofinjuryor,inanoccupationaldiseaseclaim,thedateofdisability. Shouldanemployeesustainaninjuryoroccupationaldiseaseinanemployer-sponsoredrecreational activityorfitnessprogramwhich is not listed,theemployeemaybeeligibleforworkers'compensation benefits. Recreationalactivities/Fitnessprograms The undersigned declares that he or she is a voluntary participant in the employer-sponsored recreationalactivitiesorfitnessprogramslistedabove.Heorsheherebywaivesandrelinquishesallrights toworkers'compensationbenefitsunderChapter4123oftheORCforanyinjuryordisabilityincurredwhile participatingintheaboveactivitiesorprograms.Thiswaiverisvalidfortwocalendaryears.Thewaiver maynotbaranyworkers'compensationclaimfiledfordeathbenefitsbytheemployee'sdependents. Employeesignature BWC-1286(12/29/1997) Datesigned C-159(previouslyOIC-0161) American LegalNet, Inc. www.FormsWorkFlow.com