Employer Incentive Contract Injured worker name Claim number 1. The employer agrees to employ the injured worker as an employee with all the rights, privileges and responsibilities of all other similarly situated employees, with employment as __________________________________________. 2. This employment is to begin on _________________________. The full gross wage to be paid to the injured worker is $ _____________ per hour or $_______________ per week. BWC shall reimburse the employer for a portion of the injured worker's wages according to the distribution below. Number of weeks From: From: From: From: From: From: Total weeks Period of reimbursement To: To: To: To: To: To: Employer contribution % Amount paid % BWC contribution Amount paid % Total paid % Total paid 3. Any time the injured worker works more than compensation for such hours. hours per day or hours per week, the employer will pay 4. Reimbursement of incentive monies can only occur when BWC receives documentation of gross wages (i.e. signed payroll records) paid to the injured worker for the applicable reimbursement period. 5. The employer understands that BWC's reimbursement for the employment or re-employment of the injured worker is a discretionary function of BWC. 6. This agreement shall be in full force and effect until canceled by the employer or revocation of approval by BWC with 10 days written notice to all parties, or upon the termination of the injured worker's employment. Warning: Any person who obtains compensation benefits from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statements or accepting compensation or benefits to which he/she is not entitled, is subject to felony criminal prosecution for fraud. Authorized employer name BWC policy number Address Employer representative signature (Name and title) Injured worker signature Vocational rehabilitation case manager signature FEIN City State Nine-digit ZIP Code Date Date Date BWC-2970 (Rev. Oct. 5, 2015) RH-19 American LegalNet, Inc. www.FormsWorkFlow.com