Wage Agreement
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Wage Agreement Form. This is a Ohio form and can be use in Injured Workers Workers Comp.
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Tags: Wage Agreement, BWC-1123, Ohio Workers Comp, Injured Workers
Wage Agreement
Instructions
• Submit this form prior to payment by BWC to avoid a possible
overpayment to the employee.
• Employer and employee must sign and date this agreement.
• Mail or fax this completed form to your local BWC service
ofice.
Employee name
Employer name
Date of injury
Claim number
Telephone number
(
)
The employer has paid or agrees to pay an advancement of wages to the above employee until the payment
of temporary total compensation begins. Advancement of wages begin on _______________________ to
______________________ at a rate of $ __________ per week for a total of $ _______ ___ .
By signing this agreement, the employer and employee have entered into a wage agreement to reimburse the
employer at least to the extent of any compensation paid to the employee over the same period in which the
employer paid wages or made advancements.
This agreement shall grant BWC the authority to send warrants for temporary total compensation to the employee
in care of the employer for no more than the irst 12 weeks of compensation closely following the date of injury.
BWC may pay a wage agreement beyond 12 weeks involving special circumstances.
Employee signature
Date
Employer signature and title
Date
BWC-1123 (6/13/2001)
C-18
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