Common Contracts
1 similar Disability Agreement contracts
Disability AgreementDisability Agreement • August 29th, 2013
Instructions: This form must be submitted whenever you file for disability as an advancement of Worker’s Compensation. Photocopies cannot be accepted. All blanks must be completed. Alteration of this form or failure to fill in all blanks may result in the form being returned to you. This will cause a delay in the processing of your claim. Name State of Ohio User ID On the day of , , at Ohio, in the County of , this agreement between the State of Ohio, the Department of Administrative Services, Benefits Administration Services, Disability section hereafter referred to as DAS, and , Employee, was executed under the following terms and conditions: Employee has filed an application for disability leave benefits for a disability resulting from an injury or illness received on , . Employee has been denied an initial claim for Workers’ Compensation Lost Time Wages by the Bureau of Workers’ Compensation and is appealing the BWC order denying lost time benefits. DAS agrees to pay a reimbursabl
