The Formal Modified Duty Job Offer Process Toolkit - Pinnacol ...

The Job Offer Letter should be created on your company’sletterhead and include the information below.Sample Mailed Job Offer Letter (Temp Agency)1Date:Name of Employee:Employee Address:Claim #:Date of Injury:Dear (Injured worker’s name):Certified Mail:Return Receipt Requested:Certified Mail#:SAMPLE[Proof of certifiedmailing]Your treating physician has released you to modified work. We have identified a temporary position foryou, which your physician states you will be able to perform. Please refer to the attached job task list.2The job is: See Attached. You will receive $_____ per hour.[Specify dollar amount]This modified duty job will begin at _____ on _____. Please report for work at this time and date.[7 business days from date mailed; 10 days if out of state]3Your work schedule is as follows:Hours/day and days/week:Report to:Location:[Work shift as approved by treating physician]Report Time:Phone:If the above job should no longer be available, we expect that you will contact the above statedcompany representative on a (daily/weekly) basis at the above location by (phone/in person) by(time) in the (morning/afternoon). This will be your only written employment offer notification, asfuture offers of employment will be based on the contact procedure state above. If you fail to timelyrespond to this offer of employment, temporary benefits will be terminated.Sincerely,Employer’s Signature4Enc.: Signed copy of Task Letter to Treating Provider dated _____________________.[Task Letter must be signed and dated by the treating physician]Cc: Injured WorkerCc: Attorney (if appropriate)Regular MailCertified Mail Number: _______[Include the injured worker’s name and address][Include the attorney’s name and address]1.800.873.7242 | www.pinnacol.com