Certification Agreement Between Worker And Provider (Contractor) {BWC-3938}

BWC-3938 -- CERTIFICATION AGREEMENT BETWEEN THE INJURED WORKER AND SERVICE PROVIDER (CONTRACTOR). This form is used by the Bureau of Workers' Compensation to document agreements between injured workers and service providers (contractors) regarding the completion of work related to modifications or services provided as part of a workers' compensation claim. The form includes fields for claim number, injured worker information (name, date of injury, address), details of the service(s) provided, total cost, and description of the service(s) completed. Both the injured worker and contractor certify that the work listed has been completed according to the original authorization, unless permission for variance was granted by the Bureau of Workers' Compensation. They also agree that any agreement for completion of the work is solely between them and that the Bureau of Workers' Compensation is only a third-party payer with no additional liability. Any disputes regarding the quality or performance of the work are not to be sought through or from the Bureau of Workers' Compensation. The form requires signatures from the injured worker and contractor, along with dates, contractor name, contractor signature, and contractor address. www.Formsworkflow.com