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Form

Description

froi.pdf First Report of an Injury, Occupational Disease or Death
FROI-ES.pdf First Report of an Injury, Occupational Disease or Death (Spanish)
a-12.pdf A.C.T. Enrollment and Direct Deposit Authorization
a-12-ES.pdf A.C.T. Enrollment and Direct Deposit Authorization (Spanish Version)
a-21.pdf Electronic Benefit Card
a-21-ES.pdf Electronic Benefit Card (Spanish Version)
a-35.pdf Direct Deposit ACT Bank Change
a-35-ES.pdf Direct Deposit ACT Bank Change (Spanish Version)
c-5.pdf Application for Death Benefits And/Or Funeral Expenses
c-5-ES.pdf Application for Death Benefits And/Or Funeral Expenses (Spanish Version)
c-6.pdf Application for Accrued Compensation
c-11.pdf ADR Appeal to the MCO Medical Treatment/Service Decision
c-11-ES.pdf ADR Appeal to the MCO Medical Treatment/Service Decision (Spanish Version)
c-17.pdf Outpatient Medication Invoice
c-18.pdf Notice to BWC of the Injured Worker and Employer Agreement and Authorization to Send Injured Worker's Check(s) to the Employer
c-23.pdf Notice to Change Physician of Record
c-30.pdf Request for Medical Information
c-32.pdf Application for Payment of Lump Sum Advancement
c-39.pdf Annual Death Benefits Questionnaire
c-59.pdf Self-Insurer's Agreement as to Compensation on Account of Death
c-60.pdf Injured Worker Statement for Reimbursement of Travel Expense
C-60-A.pdf Injured Worker Reimbursement Rates for Travel Expense
C-72.pdf Consent to Release Information
c-72-ES.pdf Consent to Release Information (Spanish Version)
c-77.pdf Injured Worker's Change of Address Notification
c-84.pdf Request for Temporary Total Compensation
c-84-ES.pdf Request for Temporary Total Compensation (Spanish)
c-86.pdf Motion
c-86-ES.pdf Motion (Spanish)
c-92.pdf Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability
c-92-ES.pdf Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability(Spanish)
Wages-IW.pdf Injured Worker Earnings Statement
Wages-IW-ES.pdf Injured Worker Earnings Statement (Spanish Version)
Wages-Emp.pdf Employer Report of Employee Earnings - formerly Wage Statement (C-94A)
Wages-EMP-ES.pdf Employer Report of Employee Earnings - formerly Wage Statement (C-94A) (Spanish Version)
C-101.pdf Authorization to Release Medical Information
C-101sp.pdf C-101-ES Authorization to Release Medical Information (Spanish)
C-108.pdf Waiver of Appeal Period
c-108-ES.pdf Waiver of Appeal Period (Spanish Version)
C-140.pdf Initial Application for Wage Loss Compensation
c-141.pdf Wage Loss Statement for Job Search
C-142.pdf Employer Report of Employee Earnings for Wage Loss Compensation
ic-167-t.pdf Objection to Tentative Order
C-159.pdf Waiver of Workers' Compensation Benefits for Recreational or Fitness Activities
c-159-ES.pdf Waiver of Workers' Compensation Benefits for Recreational or Fitness Activities (Spanish)
c-230.pdf Authorization to Receive Workers' Compensation Check
c-230-ES.pdf Authorization to Receive Workers' Compensation Check (Spanish)
C-240.pdf Settlement Agreement and Application for Approval of Settlement Agreement
C-240A.pdf Claimants Notice of Exception to Employers Signature Requirement
C-241A.pdf Amended Settlement Agreement and Release
c-255.pdf Affidavit for Attorney Fees
C-262.pdf Self-Insured Employer's Certification of Assignment After Initial Allowance
C-263.pdf State Fund Employer's Agreement to Accept Claim Assignment
C-264.pdf Request to Correct Employer and/or Policy Number Assignment
MEDCO-31.pdf Request for Prior Authorization of Medication
PERRP.pdf Summary of Work Related Injuries and Illness
OD-58-22.pdf Application for Adjustment of Claim in Case of Death Due to Occupational Disease
r-2.pdf Injured Worker Authorized Representative
r-2-ES.pdf Injured Worker Authorized Representative (Spanish Version )
r-4.pdf Application for Representative Identification Number (RIN)
RH-1.pdf Rehabilitation Agreement
RH-6.pdf On-the-Job Training Agreement
RH-7.pdf Loan/Release Agreement for Tools And Equipment
rh-8.pdf Vocational Rehabilitation Closure Report - Addendum
RH-10.pdf Injured Worker's Record of Job Search Contacts
rh-13.pdf Work Trial Agreement
rh-14.pdf Job Modification Agreement - Supplier Reimbursement
rh-15.pdf Job Modification Agreement - Return-to-Work (RTW) Employer
RH-18.pdf Authorization for Living Maintenance Wage Loss
RH-24.pdf Gradual Return to Work Agreement
rh-42.pdf Vocational Rehabilitation Initial Assessment Report
rh-43.pdf Vocational Rehabilitation Assessment Plan
rh-44.pdf Vocational Rehabilitation Comprehensive Plan
rh-45.pdf Authorization Request for Vocational Rehabilitation Plan
rh-46.pdf Vocational Rehabilitation Progress Report
rh-47.pdf Vocational Rehabilitation Job Retention Plan
SH-6.pdf PERRP Complaint Form
SH-27.pdf Application for Workplace Wellness Grant Program
SH-53.pdf Application for Safety Intervention Grant
SI-28.pdf Filing of an Allegation Against a Self-Insured Employer
SI-42.pdf Self Insured Joint Settlement Agreement and Release
SI-43.pdf Acknowledgment of the Self-Insured Joint Settlement Agreement and Release Instructions
SubroRefer.pdf BWC Subrogation Referral Form
ac-18.pdf Labor Lease Transaction Payroll
ac-19.pdf Labor Lease Transaction Claims
ac-2.pdf Permanent Authorization
ac-2-ES.pdf Permanent Authorization (Spanish Version)
ac-3.pdf Temporary Authorization to Review Information
ac-3-ES.pdf Temporary Authorization to Review Information (Spanish)
ac-4.pdf Request for Business Transfer Information
C-9-A.pdf Request for Additional Medical Documentation for C-9
C-55.pdf Salary Continuation Agreement
C-110.pdf Agreement to Select the State of Ohio as the State of Exclusive Remedy
C-112.pdf Agreement to Select a State Other than Ohio as the State of Exclusive Remedy
C-174.pdf Self-Insured Semiannual Report of Claim Payments
C-261.pdf Workers' Compensation Claim Log
CHP-4A.pdf Application for Handicap Reimbursement
DFSP-1.pdf Accident Report
DFSP-3Sample.pdf DFSP-3 Drug-Free Safety Program (DFSP) Annual Report Basic and Advanced Levels (sample)
DFSP-4Sample.pdf DFSP-4 Drug-Free Safety Program (DFSP) Annual Report - Comparable Program Only (sample)
DFSP-5.pdf DFSP-5 DFSP Safety Action Plan
LEGAL-16.pdf Settlement Application for Non-complying Employer Claims
MEDCO-6.pdf Waiver of Examination
MEDCO-8.pdf Self Insured Employer/Injured Worker Screening
OCP-1.pdf Application for One Claim Program *Filed Online Only*
R-1.pdf Employer Authorized Representative
RH-5.pdf Trainers Report
RH-19.pdf Employer Incentive Contract
RH-94A.pdf Report of Earnings for Living Maintenance Wage Loss Compensation
PayrollAmend.pdf Amended Payroll Report
SA-5.pdf PDP Self-Assessment
SI-6.pdf Initial Application by Employer for Authority to Pay Compensation Etc. Directly
SI-7.pdf Application for Renewal of Authorization to Operate as a Self-Insured Risk
SI-8.pdf Rehabilitation Election
SI-16.pdf Agreement Between Employer and the Ohio BWC Regarding Amount of Self-Insured Buyout
SI-38.pdf Unconditional and Continuing Guarantee
SI-40.pdf Report of Paid Compensation and Statistical Information
SI-41.pdf Handicap Reimbursement Program Withdrawal Form
SI-44.pdf Election to Withdraw from Claims Reimbursement Fund
SI-51.pdf Application for Certification of Qualified Health Plan (QHP
TWB-1.pdf Application for Transitional Work Bonus Program
TWB-2.pdf Transitional Work Offer and Acceptance Form
TWG-1.pdf Application for Transitional Work Grant Program
TWG-2.pdf Transitional Work Grant Reimbursement Request Form
TWG-3.pdf 2012 Transitional Work Grant Agreement (9/12)
twd-115.pdf Transitional Work Developer's Application
UA-3SI-1.pdf Self-Insured Professional Employer Organization (PEO) Client Relationship Notification
U3.pdf Application for Ohio Workers Compensation Coverage
U3-ES.pdf Application for Ohio Workers Compensation Coverage (Spanish)
U-3E.pdf Application for Exemption from Ohio Workers' Coverage and Waiver of Benefits
U-3S.pdf Application for Elective Coverage
U-3S-ES.pdf Application for Elective Coverage (Spanish)
UA-3.pdf Professional Employer Organization Client Relationship Notification
UA-6.pdf 10-Step Business Plan Plan of Action (POA)
U-108.pdf Opt Out of .99 EM Construction Cap Program
U-19.pdf Public Employer Agreement for 100-percent EM Cap
U-20.pdf Application for Retrospective Rating Plan For Private Employers
U-21.pdf Application for Retrospective Rating Plan for Public Employers
U-59-1.pdf Request for Retroactive Coverage and Penalty Abatement and/or a One-time Forgiveness
U-117.pdf Notification of Policy Update
U-118.pdf Notification of Business Acquisition/Merger or Purchase/Sale
U-131.pdf Notice of Election to Obtain Coverage from Other States for Employees Working Outside of Ohio
U-140.pdf Application for Drug-Free Workplace Program and Drug-Free EZ
U-145.pdf Lump Sum Settlement (LSS)
U-147.pdf Non-Ohio Amended Payroll Report
U-148.pdf Application for Deductible Program
U-149.pdf Sponsor Certification Application
U-159.pdf Other States Coverage Trucking Supplemental Application
PayrollExtPayPlan.pdf Extended Payment Plan
cover.pdf Fax Cover Sheet
c-9.pdf Physicians Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease
C-19.pdf Service Invoice
C-143.pdf DEP Physician's Report of Work Ability
C-190.pdf Justification of Necessity for Seating/Wheeled Mobility
C-196.pdf Amputation/Loss of Use Diagram
MEDCO-12.pdf Request to Change Provider Information
MEDCO-13.pdf Provider Enrollment and Certification
MEDCO-13a.pdf Provider Enrollment Application (certification not required)
MEDCO-14.pdf Physician's Report of Work Ability
MEDCO-30.pdf Disability Evaluator Application
RH-2.pdf Individualized Vocational Rehabilitation Plan
RH-21.pdf Vocational Rehabilitation Closure Report
LEGAL-15.pdf Application for Adjudication Hearing
MEDCO-32.pdf Request for Prior Authorization of Non-Preferred Medication
ic8-9.pdf Application for Additional Award for Violation of Specific Safety Requirement in a Workers' Compensation Claim
U-18.pdf Private Employer Agreement for 100-percent EM Cap
U-142.pdf Drug-Free Self-Assessment Progress Report
UA-5.pdf Application for the Premium Discount Program
MEDCO-16.pdf Mental Health Notes Summary
MEDCO-22.pdf Medication Physician Review
MEDCO-34.pdf MCO Request for Drug Utilization Review
MEDCO-35.pdf Formulary Medication Request Form