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 American LegalNet, Inc. www.FormsWorkFlow.com