Date:
(Enter Employees Name & Address Here)
RE: Employer :
Claim # :
Dear :
We are pleased to offer temporary work while you recover from your industrial injury/illness. Your
provider released you to perform the work activities outlined in the attached job analysis/description.
Please report for work to (Supervisor), on (Date & Time),* at (Location Address). Your supervisor can
be contacted at (Telephone Number).
Your work schedule will be: (Scheduled Hours/Scheduled Days).
You will be paid $( ) per hour.
{Your health care benefits will resume at the level provided at the time of injury.} or
{We are unable to offer the same health care benefits due to a change in our benefit program.}
If your job involves fewer hours or reduced wages, you may be eligible for Loss of Earning Power (LEP)
benefits. Contact your claim manager for more information.
If you want to return to work earlier or need more time, please call to discuss. We are happy to work with
you.
It is our goal that this temporary assignment will aid in your recovery while you transition back into full
work activities. It is our hope this job will support/recognize you as a valued employee. If you have
difficulty performing the tasks you are assigned, you must notify your supervisor immediately.
Your signature below acknowledges that you have reviewed this job offer. Declining this job may affect
compensation benefits.
______________________________ __________
(Worker's Signature) (Date)
____ Yes, I accept this offer
____ No, I do not accept this offer (please comment below)
Comments:
If you have any questions concerning this matter, please contact me at_xxx-xxx-xxxx.___________
Sincerely,
cc: Claims Manager
Vocational Provider
Attending Provider
Enc: Approved Job Analysis/Description
Self Addressed Stamped Envelope and respectful work environment
