Instructions: Edit any information below and click "Export Word" to generate the document.
Via Certified and Regular Mail or by Personal Service
, Esq.
[Insert Attorney Address Line 1]
[Insert Attorney Address Line 2]
[[formData.employeeName]]
v.
/Rule 6 Offer Letter
W.C no.
W.C no.
Dear
[[formData.mrMs]]
,
This will confirm our discussion today.
has been able to identify an opportunity for you to work within your
restrictions as a Staff Assistant in a temporary transitional assignment. We are pleased to offer you this approved light duty position, submitted to you in compliance with WCRP 6-1(A)(4). In addition, the company will give back to the community by donating your time to a local charity.
[[formData.jobSiteName]] has identified a modified job which your designated treating physician,
Dr.
,
has reviewed and approved.
Dr. [[formData.physicianLastName]] has determined you are capable of performing this job. Please see the attached job description letter that has been approved and signed by
Dr. [[formData.physicianLastName]]. You will participate in a light duty opportunity from your home. This assignment is scheduled to begin on
.
You will be provided with the materials required to be successful in this
assignment, as well as training from the nonprofit organization on your assigned tasks. You will be supporting the
mission.
You will be loaned the equipment necessary to complete your assigned tasks, including a tablet with protective case, headset, mouse, and keyboard. It is expected that you treat this valuable equipment with care and return per provided instructions in the condition that it was received at the conclusion of your assignment. Should this equipment not be returned within fourteen days of completing your assignment, you may be billed for these materials.
You will be reporting to a Charity Supervisor,
.
Your work schedule will be
Your hours worked will
be logged via your provided electronic tablet. Both you and your Charity Supervisor will review and electronically sign the timesheet. Once signed by both parties, it will be submitted for processing to payroll.
In addition, you will be working with
,
your Transitional Work Solutions Coordinator.
[[coordinatorName]] will be available to you at
should you have questions about the materials provided to you for your assignment.
Your Job duties in this transitional work will include:
This work all
falls within your
work restrictions of:
,
issued by Dr.
[Insert Doctor's Name]
on
[Insert Date of Restrictions].
You will
be properly trained by your Charity Supervisor to perform these duties.
You will be paid your regular wages for the time you actually work. Tell your Charity Supervisor and Transitional Work Solutions Coordinator in advance when you must leave your temporary work assignment to attend a doctor’s appointment. Your doctor’s appointments must be logged appropriately daily on your electronic tablet.
Should physical therapy be required, your appointments should be scheduled around your work schedule.
at 3CU can assist you in scheduling any appointments, if needed.
You can reach
at
.
If you are going to be late or will not be coming to work, please email your Charity Supervisor and TWS Coordinator at least one hour in advance of your scheduled shift and provide a reason why you are late or unable to work that day.
You are employed by the company and you are representing [[formData.jobSiteName]] at this site. Thus you must present yourself in a professional manner. All of our work and safety rules apply. You are working for [[formData.jobSiteName]], and you are covered by our workers’ compensation carrier.
We will work with you and your treating doctor to change your job duties as your doctor’s reports illustrate updated restrictions. Your program duration will last until release to work with no restrictions, or restrictions that may be reasonably accommodated by the employer, Maximum Medical Improvement identified, or end of a sixty (60) day calendar period; whichever occurs first. Should you reach the end of 60 days, your assignment will be re-evaluated every thirty (30) days thereafter.
Please contact me at
with any questions.
Please have your attorney, [[formData.lawyerName]] Esq., contact me with any questions or concerns you may have. We look forward to seeing you and wish you a continued and speedy recovery.
Very truly,
[[formData.jobSitePhone]]
Enclosures (3): Job Description Approval Letter, Light Duty Job Description, Driving Directions
| CC: | [[formData.employeeName]], via USPS mail [[formData.lawyerName]], Esq. via email or fax [[formData.employerLawyerName]], Esq. via email or fax [[formData.claimsAdjusterName]] , , via email |
CERTIFICATE OF SERVICE
Certified that this letter was delivered by __________ hand, or by ________ mail (Certified letter # ____________) on ____________ to the following parties by [[formData.jobSiteName]]
[[formData.employeeName]]
[[formData.employeeAddress]]
[[formData.employeeCityStateZip]]
[[formData.lawyerName]]
[[formData.lawyerFirm]]
[Insert Attorney Address Line 1]
[Insert Attorney Address Line 2]
Signed _________________________________________________________________________________
Program Acceptance/Refusal
I, [[formData.employeeName]], have received and accept the modified duty offer:
Employee Signature _____________________________________________________
I, [[formData.employeeName]], refuse the modified duty assignment:
Employee Signature _____________________________________________________
Date ___________________