Better Workers' Compensation Built with you in mind. INSTRUCTIONS: · Please print or type. · Make sure to enter 4 digits for the year in all date fields. · See example of completed form on the reverse side. · Follow the distribution list at the bottom of this form. A WEEKS OF GRTW From: From: From: From: From: From: From: From: From: From: From: From: From: To: To: To: To: To: To: To: To: To: To: To: To: To: B HRS WRKD PER WK C HRS NOT WRKD PER WK x x x x x x x x x x x x x D WAGES EARNED an hr = an hr = an hr = an hr = an hr = an hr = an hr = an hr = an hr = an hr = an hr = an hr = an hr = E WAGES NOT EARNED x x x x x x x x x x x x x an hr = an hr = an hr = an hr = an hr = an hr = an hr = an hr = an hr = an hr = an hr = an hr = an hr = GRADUAL RETURN TO WORK LIVING MAINTENANCE REIMBURSEMENT METHOD G I F H CURRENT LM RATE WEEKLY RATE FOR GRTW NEW LM RATE IW'S TOTAL WEEKLY SALARY D+H= D+H= D+H= D+H= D+H= D+H= D+H= D+H= D+H= D+H= D+H= D+H= D+H= Date Date Date Injured worker signature Employer representative signature Vocational rehabilitation case manager signature NOTE: The Rehabilitation Consultant will have the authority to correct any mathematical errors. BWC-2975 (Rev. 3/10/1999) Distribution: BWC claim file, Injured worker, Injured worker representative, Employer, Employer representative 2002 © American LegalNet, Inc. RH-25 INSTRUCTIONS GRTW LM REIMBURSEMENT METHOD Example: An IW who earns $12.00 per hour would have earned $480.00 for a 40 hour week. The recommendation from the POR shows that the IW will be able to return to work for five hours per day for the first week, six hours per day for the second week, and seven hours per day for the third week. The chart below outlines how the IRS calculates the GRTW weekly rate. A WEEKS OF GRTW B HRS WRKD PER WK C HRS NOT WRKD PER WK D WAGES EARNED E WAGES NOT EARNED F CURRENT LM RATE G WEEKLY RATE FOR GRTW H NEW LM RATE I IW'S TOTAL WEEKLY SALARY 05/20/1998 to 05/26/1998 05/27/1998 to 06/02/1998 06/03/1998 to 06/09/1998 25 30 35 15 10 5 25 hr X 12.00/hr = $300 30 hr x 12.00/hr = $360 35 hr x 12.00/hr = $420 15 hr X 12.00/hr = $180 10 hr x 12.00/hr = $120 05 hr x 12.00/hr = $060 $301.15 $301.15 $301.15 $121.15 $181.15 $241.15 $180 $120 $60 D + H = $480 D + H = $480 D + H = $480 The amount in Column E is subtracted from the amount in Column F to arrive at the amount in Column G. The amount in Column G is the amount that is to be entered as the weekly rate for the GRTW. The difference between Column F and Column G equals the new LM rate, which shown in Column H. The IW's salary while in GRTW plan, is shown in Column I. 2002 © American LegalNet, Inc.