State Fund Employer’s Agreement
to Accept Claim Assignment
Instructions
Complete this form when you are accepting assignment of a claim that BWC or another party erroneously assigned to another state-
fund employer.
Injured worker name
Date of injury
Claim number
Employer name
Employer policy number
Employer phone number
Address
City
State
ZIP code
By signing this form, I acknowledge the following:
I accept reassignment of the above-listed claim to my policy number. I agree to accept responsibility for the above-listed
claim and the risk associated with any and all medical benefits and compensation previously paid or to be paid in the claim. I
understand that BWC may, upon execution of this agreement, assign the claim to my company and policy number.
Please include comments or exceptions below.
Comments
I certify the information provided is correct to the best of my knowledge. I am aware that any person who knowingly makes a
false statement, misrepresentation, concealment of fact, or any other act of fraud is subject to felony criminal prosecution and
may, under appropriate criminal provisions, be punished by a fine, imprisonment or both.
Signature
Title
Date signed
BWC-1395
C-263
State Fund Employer’s Agreement
to Accept Claim Assignment
Instructions
Complete this form when you are accepting assignment of a claim that BWC or another party erroneously assigned to another state-
fund employer.
Injured worker name
Date of injury
Claim number
Employer name
Employer policy number
Employer phone number
Address
City
State
ZIP code
By signing this form, I acknowledge the following:
I accept reassignment of the above-listed claim to my policy number. I agree to accept responsibility for the above-listed
claim and the risk associated with any and all medical benefits and compensation previously paid or to be paid in the claim. I
understand that BWC may, upon execution of this agreement, assign the claim to my company and policy number.
Please include comments or exceptions below.
Comments
I certify the information provided is correct to the best of my knowledge. I am aware that any person who knowingly makes a
false statement, misrepresentation, concealment of fact, or any other act of fraud is subject to felony criminal prosecution and
may, under appropriate criminal provisions, be punished by a fine, imprisonment or both.
Signature
Title
Date signed
BWC-1395
C-263
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