Application for Transitional Work Bonus Program Instructions Complete all fields in this application. BWC cannot process incomplete applications. An officer, partner or owner must sign this application. You may submit the completed form in one of three ways listed below. Online: www.bwc.ohio.gov Fax: 614-621-5758 Mail: Attention: Transitional Work Bonus Program Ohio Bureau of Workers' Compensation 30 W. Spring St., 21st floor Columbus, OH 43215-2256 Employer information Name of employer and DBA Address City Employer contact for Transitional Work Bonus Program Email address for Transitional Work Bonus Program contact State Phone number Total number of employees reported under this policy number ZIP code Federal tax ID number BWC policy number Deadline for application receipt The last business day in May for the July 1 ­ June 30 program period ­ private employers only. The last business day in November for the Jan. 1 ­ Dec. 31 program period ­ public taxing district employers. Note A company applying for the Transitional Work Bonus Program must have: o A transitional work plan developed with a BWC grant between 2001 and 2006 that has been reviewed and approved by BWC for updates or; o A company-created transitional work plan reviewed and approved by BWC or; o An approved transitional work plan under the new grant program starting July 1, 2012. Applying for the program is an annual requirement. BWC will not automatically enter the company in the next program period. While participating in Transitional Work Bonus Program, you should verify other BWC programs that are compatible with it. You may participate in more than one BWC program. However, only certain programs may be combined in the discount calculation. Please reference the compatibility chart found in Ohio Administrative Code (OAC) 4123-17-74. I hereby certify that my company is applying for the Transitional Work Bonus Program pursuant to OAC 4123-17-55(D). I also certify that my company will meet, at minimum, the requirements associated with successfully utilizing my company's approved transitional work program in returning my injured employees to work. I understand that if my company does not meet the requirements, I agree to repay any benefits received. Also, I certify this information is accurate and, if not, may subject the employer applicant and myself to civil and criminal penalties. Name of designated representative certifying intent to comply and willingness to pay back bonus for non-compliance. Owner/partner; officer name Title Signature Date signed BWC-3000 (Rev. Nov. 3, 2014) TWB-1 American LegalNet, Inc. www.FormsWorkFlow.com