Gradual Return to Work Agreement Instructions • Please print or type • Make sure to enter four digits for the year in all date fields. • Follow the distribution list at the bottom of the form. Claim number Injured worker name Job title Name of employer 1. The employer will employ the injured worker on a gradually increasing schedule (see grid below) in the position listed above. The injured worker will have all the rights, privileges and responsibilities of all other similarly situated employees with the exception of the following: The injured worker will begin gradual-return-to-work on__________________________________. 2. Employer reimbursement method: The employer agrees to pay the injured worker for the equivalent of full-time work for the position at the full gross wage of $__________ per hour or $_________ per week. BWC will reimburse the employer according to the grid below. 3. Injured worker payment method: The employer agrees to pay the injured worker for actual hours worked at the full gross wage of $ __________ per hour or $_________ per week. BWC pays the injured worker for hours not worked, not to exceed the injured worker’s regular living maintenance (LM) rate. 4. The employer will not extend work hours unless specifically agreed to by the employer, physician, injured worker and BWC. 5. The employer or BWC may cancel this agreement with 10 days written notice to the other parties or upon the termination of the injured worker’s employment. 6. The employer must submit documentation of gross wages (i.e., signed payroll records, as well as actual hours worked) paid to the injured worker for each pay period to BWC for verification before BWC will pay reimbursement. NOTE: BWC may use this form to reimburse the employer or to make payment to the injured worker. The weekly gradual return to work agreement (GRTW) LM rate must not exceed the injured worker’s previous weekly LM rate. Employer Injured worker Please indicate which method is being used by checking the appropriate box: reimbursement receipt of GRTW LM GRTW schedule Total weeks GRTW dates GRTW LM to be Hours Wages to be paid Reimbursement Hours Not worked worked by employer to to be paid by BWC paid by BWC to injured worker to employer injured worker $ From: From: From: $ $ $ $ $ To: $ $ To: $ $ To: $ $ To: $ $ $ To: From: $ To: From: $ $ From: 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 Nine-digit ZIP Code Employer representative signature & title Date Injured worker signature Date Managed care organization assigned vocational case manager signature Date Distribution - BWC claim file, injured worker, injured worker representative, employer, employer representative BWC-2974 (Rev. 2/12/2009) RH-24 American LegalNet, Inc. www.FormsWorkFlow.com