Job Modification Agreement - Supplier Reimbursement {BWC-2964}

Job Modification Agreement ­ Supplier Reimbursement Injured worker name RTW employer name RTW employer address RTW employer contact person Vocational rehabilitation case manager (VRCM) BWC contact name (MCO) Managed care organization contact name City Return to work (RTW) position title FEIN State RTW employer phone number VRCM phone number BWC phone number MCO phone number Claim number Policy number Nine-digit ZIP code A job modification is the removal or alteration of a physical barrier to allow an injured worker to safely perform the essential functions of a job. Description of the modifications(s) Cost Date of installation The job modification, as proposed, remains with the RTW employer. Upon BWC's approval of this agreement, BWC will purchase the modification. The RTW employer understands BWC is purchasing the modification to support the employment of the above named injured worker. The RTW employer agrees to the modification as proposed and will adopt the policies and procedures necessary to safely deploy this modification. 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. RTW employer designated management representative signature Vocational rehabilitation case manager (VRCM) signature Supplier name Supplier address City Date Date Supplier phone number State Nine-digit ZIP code BWC-2964 (Rev. March 17, 2016) RH-14 American LegalNet, Inc. www.FormsWorkFlow.com