Gradual Return-to-Work Agreement Injured worker name Claim number 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 may cancel or BWC may revoke its approval of 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-towork agreement (GRTW) LM rate must not exceed the injured worker's previous weekly LM rate. Please indicate which method is being used by checking the appropriate box: Employer reimbursement Wages to be paid by employer to injured worker Injured worker receipt of GRTW LM GRTW LM to be paid by BWC to injured worker GRTW schedule GRTW dates From: From: From: From: From: From: From: To: To: To: To: To: To: To: Total weeks Hours worked Hours Not worked Reimbursement to be paid by BWC to employer Warning: Any person who obtains compensation or 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 & title Injured worker signature Vocational rehabilitation case manager signature FEIN City State Nine-digit ZIP Code Date Date Date BWC-2974 (Rev. Nov. 17, 2015) RH-24 American LegalNet, Inc. www.FormsWorkFlow.com