Worker's Compensation Agreement
On this [Month Day, Year], this Worker's Compensation Agreement ("Agreement") is hereby established between [Your Company], located at [Your Company Address], herein referred to as the "Employer," and [Second Party], residing at [Second Party Address], herein referred to as the "Employee," collectively referred to as the "Parties."
WHEREAS, Employee is employed by Employer in the position of [Employee's Job Title] and is entitled to workers' compensation benefits in accordance with applicable state laws and regulations; and
WHEREAS, Employer wishes to provide information and guidelines to Employee regarding workers' compensation benefits;
NOW, THEREFORE, in consideration of the mutual covenants contained herein, the Parties agree as follows:
Workers' Compensation Coverage:
Employer provides workers' compensation coverage in accordance with the laws of the state of [State] to all eligible employees, including Employee.
Reporting Workplace Injuries:
Employee agrees to promptly report any workplace injuries or illnesses to their immediate supervisor or the designated HR representative of the Company within 24 hours of occurrence.
Medical Treatment:
If Employee suffers a workplace injury or illness, Employer will provide necessary medical treatment as required by state law and its insurance policy. Employee must choose a healthcare provider from a list provided by Employer or as directed by the Company's workers' compensation insurance carrier.
Compensation for Injuries:
Employee is entitled to compensation for work-related injuries or illnesses in accordance with the applicable workers' compensation laws of the state of [State]. The specific amount and duration of compensation will be determined by state law and the Company's workers' compensation insurance policy.
Return to Work:
Employee agrees to cooperate with all reasonable requests from Employer regarding return-to-work programs, including modified duty assignments, if applicable and recommended by the treating physician, in accordance with state workers' compensation laws.
Reporting Changes:
Employee shall promptly report any changes in their medical condition or work status to Employer. Failure to do so may result in the suspension or termination of workers' compensation benefits.
Legal Rights:
This Agreement does not limit Employee's rights to pursue a workers' compensation claim or to seek legal counsel. The Parties agree to cooperate fully with any investigations or legal proceedings related to a workers' compensation claim.
Confidentiality:
Employee agrees to keep all information related to their workers' compensation claim confidential, except as required by law. This includes medical records, discussions with medical professionals, and any communications with the Company's HR department.
Termination of Agreement:
This Agreement may be terminated by either party upon written notice to the other party. Termination shall not affect any workers' compensation claims or rights that have already accrued.
Entire Agreement:
This Agreement constitutes the entire agreement between the Parties with respect to workers' compensation and supersedes all prior agreements, understandings, and representations, whether oral or written.
IN WITNESS WHEREOF, the Parties hereto have executed this Worker's Compensation Agreement as of the date first above written.
EMPLOYER'S SIGNATURE EMPLOYEE'S SIGNATURE
(signature) (signature)
[Your Name] [Your Name]
HR Manager [Job Title]
[Month Day, Year] [Month Day, Year]
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