Authorization for Living Maintenance Wage Loss Instructions To be completed by the injured worker Injured worker name Address Current employer Employer address City City Check only one Claim number Initial Six month Date of injury Job change / State Job title State / Nine-digit ZIP code Nine-digit ZIP code Receives a gross weekly salary of Works Hours per week Conditions regarding the receipt of living maintenance wage loss (LMWL) I must have a release from the physician of record to return to work with restrictions at the initial authorization for LMWL. To continue to receive LMWL, I must also submit restrictions from the physician of record every six months or when current restrictions expire (whichever comes first). I must submit this information to the BWC disability management coordinator on my customer service team. I must submit at least, on a monthly basis, a copy of all my pay stubs or a payroll report from all my employers or a Report of Earnings for Living Maintenance Wage Loss Compensation (RH-94A) signed by me to the BWC disability management coordinator. If I have a job that relies on commission sales, seasonal work or self-employment, I must submit pay stubs and notarized RH-94A and a copy of my federal estimated tax for individuals. I must submit this documentation on a quarterly basis (every 13 weeks) to the BWC disability management coordinator. I must request a renewal by contacting the BWC disability management coordinator within 30 days prior to the expiration date of the current authorization. If I plan to make a change in employment after receipt of LMWL, to maintain eligibility for LMWL, I must first notify the BWC disability management coordinator assigned to my claim to maintain eligibility for LMWL. I will need to provide the job title, expected salary, and scheduled hours of the new employment. I cannot choose to work at a lower paying job for reasons unrelated to my allowed injury and continue to receive LMWL. If my employer of record was a state fund employer, then I must submit all LMWL documentation to my BWC disability management coordinator as outlined above. If my employer of record was a self insured company, I must submit all LMWL documentation to that employer. Warning: I realize I must report to BWC all income I receive for all work I perform while receiving LMWL. I understand that my failure to accurately report my income could result in my receiving LMWL to which I am not entitled. I further understand that if I fail to accurately report my full income to BWC, and in doing so, I knowingly make a false statement, misrepresent or conceal a fact or perform any other act of fraud in order to obtain LMWL, I may be subject to felony criminal prosecution and may, under appropriate criminal provisions be punished by a fine or imprisonment or both. Injured worker certification By signing below, I certify I have read and understood the statements above and agree with these conditions: Injured worker signature Date / BWC disability management coordinator verifies the following: Accident employer Policy number / Manual number Pre-injury full weekly wage $ Originally was authorized for LMWL on Pre-injury average weekly wage $ Check box if injured worker has a substantial variation in income Return to work on Expiration date of this LMWL Authorization / / / / / Date / / BWC disability management coordinator signature / BWC-2968 (Rev. April 7, 2016) RH-18 American LegalNet, Inc. www.FormsWorkFlow.com