Form ADM4313 "Disability Agreement" - Ohio

What Is Form ADM4313?

This is a legal form that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2013;
  • The latest edition provided by the Ohio Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ADM4313 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download Form ADM4313 "Disability Agreement" - Ohio

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Disability Agreement
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 reimbursable advancement of disability leave benefits in order to provide Employee with the
necessities of life, in consideration for which Employee agrees to reimburse DAS for the amounts so advanced. Employee also
understands that it is Employee’s responsibility to keep DAS notified of the status of the Workers’ Compensation claim.
Employee understands that, once an advancement is received, it is the employee’s responsibility to continue to pursue the claim
for Lost Time Wages with the Bureau of Worker’s Compensation. Failure to pursue a Workers’ Compensation claim may result
in denial of an advancement or an action by DAS to recover the amount so advanced.
Upon entitlement to weekly wage payments or upon payment of a lost time wage settlement, and as consideration for
the receipt of disability leave benefits, employee promises to pay directly to the Disability Leave Benefit Program all monies
advanced by the program for the same period of disability from which employee received a weekly payment from the Bureau of
Workers’ Compensation. Such repayment shall be made by employee in a lump sum directly to the Disability Leave Benefit
Program. If no lump sum payment is received within two (2) weeks of employee being notified of such debt, deductions of 10%
of employee’s gross earnings from employee’s pay check will be made until such a time that the debt amount is satisfied. If it
becomes necessary to initiate appropriate action by the Attorney General to recover the monies advanced by the Disability
Leave Benefit Program, then the employee agrees to pay DAS reasonable attorney fees in such suit.
This agreement shall be governed by the laws of the State of Ohio and is made with the express understanding that if
employee receives a final order from the Industrial Commission denying the Workers’ Compensation claim and the employee is
not appealing the denial into court, this agreement is null and void. If entitlement to Workers’ Compensation benefits is
approved, this agreement shall be the authority for the Bureau of Workers’ Compensation to send all warrants to employee in
care of DAS for no more than the first twelve (12) weeks of compensation closely following the date of injury.
The undersigned employee has read this agreement, understands all of its terms, and has executed such agreement
voluntarily.
SIGNED:
__________________________________________________________________________________________
DATE
EMPLOYEE
__________________________________________________________________________________________
DATE
AGENCY
__________________________________________________________________________________________
DATE
DEPARTMENT OF ADMINISTRATIVE SERVICES
BENEFITS ADMINISTRATION SERVICES
ADM 4313 (rev 09/13)
Disability Agreement
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 reimbursable advancement of disability leave benefits in order to provide Employee with the
necessities of life, in consideration for which Employee agrees to reimburse DAS for the amounts so advanced. Employee also
understands that it is Employee’s responsibility to keep DAS notified of the status of the Workers’ Compensation claim.
Employee understands that, once an advancement is received, it is the employee’s responsibility to continue to pursue the claim
for Lost Time Wages with the Bureau of Worker’s Compensation. Failure to pursue a Workers’ Compensation claim may result
in denial of an advancement or an action by DAS to recover the amount so advanced.
Upon entitlement to weekly wage payments or upon payment of a lost time wage settlement, and as consideration for
the receipt of disability leave benefits, employee promises to pay directly to the Disability Leave Benefit Program all monies
advanced by the program for the same period of disability from which employee received a weekly payment from the Bureau of
Workers’ Compensation. Such repayment shall be made by employee in a lump sum directly to the Disability Leave Benefit
Program. If no lump sum payment is received within two (2) weeks of employee being notified of such debt, deductions of 10%
of employee’s gross earnings from employee’s pay check will be made until such a time that the debt amount is satisfied. If it
becomes necessary to initiate appropriate action by the Attorney General to recover the monies advanced by the Disability
Leave Benefit Program, then the employee agrees to pay DAS reasonable attorney fees in such suit.
This agreement shall be governed by the laws of the State of Ohio and is made with the express understanding that if
employee receives a final order from the Industrial Commission denying the Workers’ Compensation claim and the employee is
not appealing the denial into court, this agreement is null and void. If entitlement to Workers’ Compensation benefits is
approved, this agreement shall be the authority for the Bureau of Workers’ Compensation to send all warrants to employee in
care of DAS for no more than the first twelve (12) weeks of compensation closely following the date of injury.
The undersigned employee has read this agreement, understands all of its terms, and has executed such agreement
voluntarily.
SIGNED:
__________________________________________________________________________________________
DATE
EMPLOYEE
__________________________________________________________________________________________
DATE
AGENCY
__________________________________________________________________________________________
DATE
DEPARTMENT OF ADMINISTRATIVE SERVICES
BENEFITS ADMINISTRATION SERVICES
ADM 4313 (rev 09/13)