In the complex landscape of workers' compensation, the C 159 form emerges as a critical document for employees willingly participating in employer-sponsored recreational or fitness activities. This form, essentially a waiver, allows employees to relinquish their rights to workers’ compensation benefits specifically for injuries or illnesses derived from these voluntary activities. The process requires employees to meticulously list all the employer-sponsored activities for which they're choosing to waive coverage, ensuring a clear understanding and agreement between the employer and employee. Importantly, the form mandates a signature and current date from the employee to validate their acknowledgment and consent to the terms outlined. Employers are then responsible for securely maintaining the original document and providing a copy to the employee for their records. Interestingly, this waiver retains significance only until an employee potentially files a claim for an injury or occupational disease incurred during one of these activities, at which point the employer must submit this document to the Bureau of Workers' Compensation (BWC). Embedded within Ohio’s legal framework under Section 4123.01(C)(3) of the Ohio Revised Code (ORC), this document delineates a clear process but also underscores the employee's responsibility in understanding the implications of waiving workers’ compensation benefits. This waiver remains effective for two years, unable to affect claims related to employee death benefits made by dependents, marking a nuanced intersection between personal choice and legal safeguards in workplace recreation.
| Question | Answer |
|---|---|
| Form Name | Form C 159 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | BWC, C-159, relinquishes, Pursuant |
Waiver of Workers’ Compensation Benefits for Recreational or Fitness Activities
Instructions
•Complete this form to waive workers’ compensation coverage for voluntary participation in
•In the space provided, list all
•The employee must sign and date this form to acknowledge agreement.
•The employer shall retain the original for his or her iles and provide a copy to the employee.
•The employer should submit a copy to BWC only when an employee files a claim for an injury or occupational disease sustained in the em- ployer- sponsored recreational activity or itness program. For further information call
Employee name (please print or type)
Date
Employer name
Risk number
Pursuant to Section 4123.01(C)(3) of the Ohio Revised Code (ORC), the employer and employee shall list those
Recreational activities/Fitness programs
The undersigned declares that he or she is a voluntary participant in the
Employee signature |
Date signed |