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Transitional Workgrant EZ Program Agreement Form. This is a Ohio form and can be use in Employers Workers Comp.
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Tags: Transitional Workgrant EZ Program Agreement, TWG-EZ-110, Ohio Workers Comp, Employers
Transitional
WorkGRANT$-EZ
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Employer full, legal name (please print or type)
Federal tax I.D. number
Employer address (city, state, ZIP code)
This is an Agreement by and between _______________________________________________________________ (hereinafter, “the employer”),
Employer full, legal name
with its principal place of business located at __________________________________________ , and the Ohio Bureau of Workers’
Compensation (hereinafter “BWC”), having offices at 30 W. Spring St., Columbus, Ohio 43215-2256, entered into the day, month and year
set out below.
Whereas, the Administrator of BWC, may issue a grant to defray the costs incurred by the employer who elects toparticipate in BWC’sTransitional
Work Program Development Grants-EZ program, also known as the Transitional WorkGRANT$ (TWG)-EZ program, pursuant to Ohio Revised
Code Section (ORC) 4123.29 and Ohio Administrative Code Rule (OAC) 4123-17-55 and4123-18-06, wherein the employermay receive grant
monies for the development of a transitional work program; now
Therefore, for good and valuable consideration, the sufficiency of which is acknowledged, the parties mutually agree tothe following:
CONDITIONS PRECEDENT. Approval of a TWG-EZ grant is contingent upon the following criteria: The employer is eligible for a TWG-EZ grant
only one time per policy number. Only state fundemployers or certain public employers are eligible for such a grant.
TASK DESCRIPTION. The employer, in consideration of the grant given to it as a participant in the BWC’s TWG-EZ program promises to pay the
transitional work developer for its work and to implement the program in good faith in accordance with OAC 4123-17-55, as amended, which
shall be incorporated as if fully rewritten herein. Where applicable, the employer participating in the TWG-EZ program in consideration of the
grant given to the employer, promises to fully comply with the program requirementsas outlined in the application,which shall be fully incorporated
herein by reference.
ELIGIBILITY AND DISTRIBUTION OF GRANT MONIES. The distribution of any TWG-EZ money for the employer participating in BWC’s TWG-EZ
program is fully dependent upon available resources of BWC. The employer and BWC mutually understand and agree as follows. The employer
may request a proposal from the current list of transitional work developers from BWC and then solicit proposals from these Developers. BWC
shall not reimburse the employer or the transitional work developers for costs associated with preparing and submitting a proposal to the
employer. Grant amounts will be based on the complexity of services needed as indicated in a proposal for transitional work services.
Factors which may determine appropriate grant amounts may include the employer’s number of employees, job classifications, job
analyses needed, and collective bargaining units. The grant monies shallnot exceed the maximum amount to which the employer is eligible,
as delineated 2600.00 in the Transitional Work Development Reimbursement Limits document, which shall beincorporated as if fully rewritten
herein.
The maximum reimbursable amounts and rates shall be those that are in effect on the date of this agreement.
The job analysis reimbursement amount per job analysis shall not exceed one hundred sixty dollars ($160.00), which shall be paid for
the actual number of job analyses performed. Each job analysis shall consist of a certain length of observation and a certain length for report
completion. The employer shall directly compensatethe transitional work developer for the developers’s services. BWC shall not reimburse the
employer for costs not deemed eligible.BWC may monitor the employer’s and the transitional work developer’s content and implementation of
transitional work services. The employer agrees to utilize the grant monies soley for the purposes outlined in this Agreement and in OAC 412317-55. If the employer receives the warrant and uses the grant monies for some other purpose, it shall immediately return the full amount to
BWC, and BWC reserves the right to recover grant money by one or more of the following methods: Billing the employer for grant money
received, forwarding to the Ohio Attorney General for collections, set-off, recoupment, or other legal remedy.
February 2004
TWG-EZ-110
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DISQUALIFICATION. If for any reason the employer participating in the BWC’s TWG-EZ program fails to satisfy the requirements of this
program in a timely manner, the employer may be disqualified from the TWG-EZ program. BWC reserves the right to conduct an on-site
eview if there is reason to believe the program has not been implemented in good faith. Sufficient reason shall include an increase in the
number or overall duration of lost-time claims after implementation of the program; such a determination maybe made by an investigation
or by data warehouse research. Sufficient reason shall also include reasonable suspicion of fraud orcollusion on the part of the employer.
The Employer, if disqualified by BWC, shall immediately return all of the monies to BWC, and BWC reserves the right to recover the grant
by the following methods: billing the employer, for the grant money received, forwarding to the Ohio Attorney General for recollection,
set-off, recoupment or other legal remedy. If the employer fails to implement the program within one (1) year, the grant monies shall be
considered misappropriated, and the employer shall repay the amount of the grant immediately, and BWC reserves the right to recover
grant money by one or more of the following methods: billing the Employer for the grant money received, forwarding to the Ohio Attorney
General for collection, set-off, recoupment, or other legal remedy.
PURPOSE AND DISCLAIMER. If implemented correctly by the employer, the goal of the TWG-EZ program is to reduce the incidence of
lost-time claims and the duration of such clams by the employees of the employer. In the event of an injury or occupational disease arising
from the implementation of the program, the employer’s and the employee’s sole and exclusive remedy shall be pursuant to workers’
compensation laws of the appropriate jurisdiction. In no event shall BWC be liable for any damages in contract or in tort.
MODIFICATIONS. The parties may in writing and by mutual agreement, amend, modify, supplement or rescind the terms of this agreement.
AUTHORITY. The person signing below for the employer states that he or she is either the owner, CEO, CFO, plant manager, or other person
having fiduciary responsibilities with the employer, and the employer agrees that that the signer or his or her successor will have the
authority to over see the carrying out of the employer’s responsibilities for two years after BWC issues the grant warrant. The signer’s
authority shall continue until the employer notifies BWC of the name of the successor. The signer on his or her own behalf and on behalf
of the employer agrees to comply fully with the terms and conditions of this Agreement and the program and to utilize all monies solely
for the purpose or purposes intended and understands that he or she and the employer may be subject to civil, criminal and administrative
penalties as a result of any false, misleading or fraudulent statement of if the monies are not used or are misused, misapplied or
misappropriated in any way.
IN WITNESS WHEREOF, the parties hereunto affix their signature this ______ day of _______________________ , 20____.
Signature ____________________________________________________
Ohio Bureau of Workers’ Compensation
Title _________________________________________________________
__________________________________________________________
James Conrad, Administrator/CEO
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