The Wage Agreement Ohio form is a document that establishes a formal understanding between an employer and an employee regarding the advancement of wages during a period of temporary total compensation. This agreement must be signed and dated by both parties before submission to the Bureau of Workers' Compensation (BWC) to prevent potential overpayments. It outlines the terms under which the employer will provide wage advancements, ensuring that both the employer and employee are aware of their responsibilities and rights.
The Wage Agreement Ohio form serves as a critical tool for employers and employees navigating the complexities of temporary wage advancements following a workplace injury. This form must be submitted to the Bureau of Workers' Compensation (BWC) before any payments are made, ensuring that potential overpayments to the employee are avoided. Both the employer and the employee are required to sign and date the agreement, solidifying their mutual understanding of the terms. The form captures essential details such as the employee's name, date of injury, claim number, and employer's information, including a contact telephone number. It outlines the specifics of the wage advancement, including the start and end dates, the weekly payment rate, and the total amount to be advanced. By entering into this agreement, both parties acknowledge that the employer will be reimbursed for any wages paid during the period that temporary total compensation is pending. Furthermore, the BWC is authorized to send compensation warrants directly to the employee, with the stipulation that these warrants must be endorsed by the employee. For unique circumstances, there may be provisions for extending the wage agreement beyond the initial 12 weeks. This form is not just a document; it represents a partnership between employer and employee during a challenging time.
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
Date of injury
Claim number
Employer name
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. The warrants must be endorsed personally by the employee. BWC may pay a wage agreement beyond 12 weeks involving special circumstances.
Employee signature
Date
Employer signature and title
BWC-1123 (10/17/2011)
C-18
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