Workers' compensation form.pdf

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Bureau of workers'. compensation. waiver of workers' compensation benefits for recreational or fitness activities. instructions.

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Bureau of Workers' Compensation Waiver of Workers' Compensation Benefits for Recreational or Fitness Activities Instructions • Complete this form to waive workers' compensation coverage for voluntary participation in employer-sponsored recreational activities or fitness programs. • In the space provided, list all employer-sponsored recreational activities and fitness programs for which the employee wishes to waive workers' compensation coverage. Make a line through any blank spaces, • The employee must sign and date this form to acknowledge agreement, • The employer shell retain the original for his or her files and provides copy to the employee, • The employer should submit a copy to BWC only when an employee files a claim for an injury or occupational disease sustained in the employer- sponsored recreational activity or fitness program. • For further Information call 1-800-OHIOBWC (1-800-644-6292). Employee name (please print or type) Date Employer name Risk number Pursuant to Sectio...

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