Loan/Release Agreement for Tools and Equipment Injured worker name Address City State Claim number Nine-digit ZIP code - Description of tool or equipment A B C D E F G QTY Cost Date item loaned Date item returned Date item released I, the injured worker, understand BWC is loaning the items above to me, and they will remain the property of BWC until released to me in writing. I understand BWC may require me to replace lost or damaged items, unless the damage is due to normal wear and tear. The managed care organization (MCO) representative will complete this Release statement, and transfer these items to me after 90 days of employment. I agree to return these items to the MCO representative if this employment is not maintained for 90 days. 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. Loan agreement I have received the above described item(s) from my MCO representative. Injured worker signature Authorized MCO representative signature Date Date Return statement The above described item(s) will be returned to BWC by my MCO representative. Injured worker signature Authorized MCO representative signature MCO Release statement The above described item(s) as indicated by my signature and today's date were released to the injured worker because I determined the item(s) would be necessary to be used in his/her employment. The injured worker has remained employed 90 days after returning to work as a result of a rehab plan. Authorized MCO representative signature Date BWC-2957 (Rev. Nov. 18, 2015) RH-7 American LegalNet, Inc. www.FormsWorkFlow.com