Notice To BWC Of Agreement To Send Check To Employer {BWC-1123}

Notice to BWC of the Injured Worker and Employer Agreement and Authorization to Send Injured Worker's Check(s) to the Employer Instructions This form is for injured workers who may qualify for temporary total disability and who have entered into an agreement with their employer to reimburse the employer for wages or sick leave paid during the disability. Fax this completed form to 1-866-336-8352, or send it to your local BWC customer service office. Claim number Date of injury Injured worker's name Agreement/Authorization The injured worker and employer must sign, date and submit this form to BWC within 30 calendar days of the beginning date of payment from the employer to the injured worker of wages, sick leave or advancement. The beginning date is the day the first payment was issued to the injured worker, not the beginning date of the period of time that is paid. The injured worker and employer are hereby giving BWC notice that you both agree the employer has paid or agrees to pay wages, sick leave or an advancement of wages to the above-named injured worker. The first payment was made on ___/___/___ at a rate of $________________ per week. The employer has paid or agrees to pay from ____/____/____ to ____/____/____. This time period cannot exceed 12 weeks unless special circumstances exist, and BWC has approved it. If the time period noted changes, the employer must notify BWC. If BWC does not receive notice of the change, BWC will not send the injured worker's compensation payments in care of the employer. By signing, the injured worker authorizes BWC to send his/her check in care of the employer for any temporary total compensation the injured worker would have been eligible to receive during the period of this agreement. The injured worker must personally endorse the warrants. I certify the information on this form is true and correct to the best of my knowledge. I understand that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain benefits and/or compensation as provided by BWC or self-insuring employers, or who knowingly accepts compensation to which that person is not entitled, is subject to criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. Injured worker's signature Date signed Employer's signature and title Date signed BWC- 1123 (Rev. May 29, 2015) C-18 www.FormsWorkFlow.com