Transitional WorkGRANT$-EZ For small business - It’s easy Application instructions Mail your completed application to: Ohio Bureau of Workers’ Compensation Transitional WorkGRANT$-EZ Program 30 W. Spring St., 22nd floor Columbus, OH 43215-2256 Employer information Application date Fax your application to (614) 621-1118. _______ _______ /________ ________ /_______ ________ ___________________________________________________________________________________________________ Employer name (DBA) ___________________________________________________________________________________________________ Contact name BWC policy number ___________________________________________________________________________________________________ Employer address ______________________________________________________________( )_____________________________ Employer e-mail address Telephone number ___________________________________________________________________________________________________ City State ZIP code ___________________________________________________________________________________________________ Managed care organization name I have hired a BWC-accredited transitional work developer. ____________________________________________ Transitional work developer (Print name.) Type of industry: J Manufacturing J Office work J Service J Public employer J Other__________________ Have you used these programs and services? J J J J J J Premium Discount Program + 10-Step Business Plan Drug-free workplace programs SafetyGRANT$ Division of Safety & Hygiene services Other __________________________________________________________________________________ Indicate your organization’s number of employees: ___________________________________________________ (Include all permanent full-time, part-time and intermittent/seasonal employees.) Do you have an existing light duty/transitional work program? J Yes J No I request education on how to select a BWC-accredited transitional work developer. J Yes J No x __________________________________________________________________________________________________ Signature of designated employer representative Date signed American LegalNet, Inc. www.USCourtForms.com BWC-2989 (11/10/2003) TWG-EZ-104