Sample Bona Fide Offer of Employment
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
Date
Injured Employee Address
City, State ZIP
Dear :
(Company’s name) would like to offer you a temporary, modified-duty job assignment at the
following location:
Company Name
Street Address
City, State, ZIP
The schedule and wages per hour for this position are:
Monday
Wages per hour
Tuesday
Wages per hour
Wednesday
Wages per hour
Thursday
Wages per hour
Friday
Wages per hour
Saturday
Wages per hour
Sunday
Wages per hour
The job duties meet the work restrictions sanctioned by doctor’s name and date of report (see enclosed
work status report).
Below is the job title, list of the job duties, maximum physical requirements, and time
requirements for this temporary, modified-duty assignment.
Job Title
Job Description (list the
responsibilities of the job)
Page 1 of 2
Maximum Physical Requirements and Time Requirements (max hours per day)
Task
Time
Task
Time
Standing
Walking
Sitting
Climbing stairs/ladders
Kneeling/squatting
Grasping/squeezing
Bending/stooping
Wrist flexion/extension
Pushing/pulling
Reaching
Twisting
Overhead reaching
Keyboarding/mouse
Driving
Lifting/carrying (include
number of pounds)
Additional duties
While you are working in this modified-duty job assignment, we will only assign tasks that are
consistent with your physical abilities, knowledge, skills, and work restrictions as sanctioned by
(doctor’s name/date).
We will provide training if necessary. If you are asked to perform duties that
you believe are not within your restrictions, please cease work immediately and contact your
supervisor.
Please sign below either accepting or rejecting this offer and return it to our office by
(month/day/year*). If we do not hear from you, we will assume you have rejected this offer.
Rejection of this offer may affect your entitlement to or amount of temporary income
benefits.
Employee’s Signature - Accepting Offer Date
Employee’s Signature – Rejecting Offer Date
Sincerely,
Name,
Title
Company
Enclosed: DWC-73, Work Status Report from (doctor’s name/date)
SAMPLE BONA FIDE LETTER OF EMPLOYMENT
Page 2 of 2
Page 2 of 2
Sample Job Description with Physical and Time Requirements
This position will entail these specific tasks in accordance with your modified duty restrictions:
• Med count and recording
o Requires sitting and/or standing up to 3 hours per day
o Requires grasping/squeezing and lifting of items less than 10 pounds
• Cooking and supervising cooking and clean up
o Requires standing/walking up to 2 hours
o Requires grasping/squeezing and lifting of items less than 10 pounds
o Requires reaching between eye and thigh level
o Other staff and/or clients will be available for tasks out of range of movement
• Running errands
o Driving to transport individuals, which will require less than 1 hour sitting and walking
o Picking up limited grocery/household items, requiring walking and sitting less than 1
hour
o Grasping, squeezing, and lifting items less than 10 pounds. Bags will weigh less than
10 pounds
o Reaching between eye and thigh level
• Completing paperwork and filing
o Sitting and up to one hour and wrist flex
• Supervising clients attending to their personal hygiene
o Standing and reaching at arm height less than one hour per day
• Light cleaning and supervising clients doing household chores
o Dusting at level between neck and hip
o Cleaning windows and sills between an area of neck height and hip height
• Client skill teaching
o Requires sitting and standing up to 8 hours per day
Your job restrictions include the following:
• No bending/stooping
• No pushing/pulling
• No working at heights
• No overhead reaching
• No lifting/carrying over 10 pounds
PO Box 12029 | Austin, Texas 78711-2029
(800) 859-5995 | Fax: (800) 224-3889 | texasmutual.com
Checklist for Making a Bona Fide Offer of Employment
To be bona fide, the offer must meet requirements set by the Texas Department of Insurance, Division of
Workers' Compensation, in rule 129.6.
The Division established these requirements because making a bona fide offer of employment can affect
an injured worker's income benefits. As an employer, extending a bona fide offer means giving your
employee the opportunity to return to work. When deciding whether an offer is bona fide, the Division
considers the following:
• Is the offer in writing?
• Is a copy of the most recent DWC-73 work status report attached?
• Does the offer specify the location at which the employee will be working, including the complete
address?
• Does the offer state the wages the employee will be paid?
• Does the offer contain a description of the physical tasks and time requirements that the position
entails?
• Is the work schedule similar to what the employee worked before the injury?
• Does the letter contain the statement “will only assign tasks consistent with the employee’s
physical abilities, knowledge, and skills”?
• Does the offer contain a statement that the employer “will provide training if necessary”?
• Is the offer at a location that is geographically accessible to the employee, including both the
location of the work and the availability of transportation?
• Is the offer consistent with the doctor’s certification of the employee’s work abilities?
• Was the offer communicated to the employee in writing with all the above requirements
included?
• Does the offer remain open for at least 7 days following the employee’s receipt of the letter?
• Is the work status report (DWC-73) upon which the offer is based shown to be enclosed?
Once the letter is completed and has been reviewed by Texas Mutual, send the offer to the injured
worker two ways by certified mail with return receipt requested and by regular mail. Additionally, please
send a copy of the letter and mail receipt to the email address, mailing address or fax number listed
below.
Email: claimdocs@texasmutual.com
Mail: Texas Mutual Insurance Company
PO Box 12029
Austin, TX 78711-2029
Fax: (512) 224-3889