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Employer Incentive Contract Form. This is a Ohio form and can be use in Employers Workers Comp.
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Tags: Employer Incentive Contract, BWC-2970, Ohio Workers Comp, Employers
Employer
Incentive Contract
Instructions
• Please print or type.
• Make sure to enter four digits for the year in all date fields.
• Case manager follow the distribution list at the bottom.
Injured worker name
Claim number
1. The employer agrees to employ the injured worker as an employee with all the rights, privileges and responsibilities of
all other similarly situated employees with employment as
.
2. This employment is to begin on ___________________________. The full gross wage to be paid to the injured
worker is $ ________________ per hour or $ ________________ per week. Due to the injured worker’s initial adjustment period, BWC agrees to reimburse the employer for a portion of the injured worker’s wages according to
the distribution below.
Period of
reimbursement
Number
of weeks
From:
To:
From:
To:
From:
Amount paid
To:
From:
BWC contribution
%
To:
From:
Employer contribution
Amount paid
To:
From:
%
To:
Total
% paid
Total
weeks
Total
% paid
3. Any time the injured worker works more than ________ hours per day or _______ hours per week, the employer
will pay compensation for such hours.
4. Reimbursement of incentive monies can only occur when BWC receives documentation of gross wages (i.e.
signed payroll records) paid to the injured worker for the contracted reimbursement period.
5. The employer understands that BWC’s offer of reimbursement in this contract, for the employment or re-employment of the injured worker, is a discretionary function of BWC.
6. This agreement shall be in full force and effect until canceled by either the employer or BWC with 10 days written notice to each of the other parties or upon the termination of the injured worker’s employment.
Warning: Any person who obtains compensation from BWC or self-insuring employers by knowingly misrepresenting or concealing facts,
making false statements or accepting compensation to which he/she is not entitled, is subject to felony criminal prosecution for fraud.
Authorized employer name
Address
City
State
9-digit ZIP Code
Employer representative signature (Name & Title)
Date
Injured worker signature
Date
Vocational rehabilitation case manager signature
Date
Distribution: BWC claim file, injured worker, injured worker representative, employer, employer representative
BWC-2970 (Rev. 10/08/08)
RH-19
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