BWC

BWC FILLABLE FORMS

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INJURED WORKER FORMS

BWC #
Form Title

A-12 A.C.T. Enrollment and Direct Deposit Authorization

A-21 Electronic Benefit Card

A-35 Direct Deposit ACT Bank Change

C-5 Addition Information for Death Benefits

C-11 ADR Appeal to the MCO Medical Treatment/Service Decision

C-17 Outpatient Medication Invoice

C-18 Wage Agreement

C-23 Notice to Change Physician of Record

C-30 Request for Medical Information

C-32 Application for Payment of Lump Sum Advancement

C-39 Annual Death Benefits Questionnaire

C-59 Self-Insurer's Agreement as to Compensation on Account of Death

C-60 Injured Worker Statement for Reimbursement of Travel Expense

C-60-A Injured Worker Reimbursement Rates for Travel Expense

C-77 Injured Worker's Change of Address Notification

C-84 Request for Temporary Total Compensation

C-86 Motion

C-92 Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability

C-94-A Wage Statement

C-101 Authorization to Release Medical Information

C-108 WAIVER of Appeal Period

C-140 Initial Application for Wage Loss Compensation

C-141 Wage Loss Statement for Job Search

C-159 Waiver Of Workers’ Compensation Benefits For Recreational Or Fitness Activities

C-167-T Objection to Tentative Order Awarding Permanent Partial Disability Compensation

C-230 Authorization to Receive Workers' Compensation Check

C-240 Settlement Agreement and Application for Approval of Settlement Agreement

FROI First Report of an Injury, Occupational Disease or Death

MEDCO-31 Request for Prior Authorization of Medication Form

MEDCO-32 Request for Prior Authorization of NON-PREFERRED Medication Form

OD-58-22 Application for Adjustment of Claim in Case of Death Due to Occupational Disease

R-2 Injured Worker Authorized Representative

RH-1 Rehabilitation Agreement

RH-6 On-the-Job Training Agreement

RH-7 Loan/Release Agreement for Tool and Equipment

RH-10 Injured Worker's Record of Job Search Contacts

RH-24 Gradual Return to Work Contract Reimbursement Method

SI-28 Filing of Allegation Against a Self-Insured Employer

SI-42 Self Insured Joint Settlement Agreement and Release

SI-43 Acknowledgement of the Self-Insured Joint Settlement Agreement and Release

INDUSTRIAL COMMISSION OF OH

BWC #
Form Title

C-11
Industrial Commission of OHIO - Request for Continuance

Please find currently available forms above. If you like to purchase a license to use or don’t find the form(s) that you need, please contact us at 614-543-1338.

BWC #	Form Title
A-12	A.C.T. Enrollment and Direct Deposit Authorization
A-21	Electronic Benefit Card
A-35	Direct Deposit ACT Bank Change
C-5	Addition Information for Death Benefits
C-11	ADR Appeal to the MCO Medical Treatment/Service Decision
C-17	Outpatient Medication Invoice
C-18	Wage Agreement
C-23	Notice to Change Physician of Record
C-30	Request for Medical Information
C-32	Application for Payment of Lump Sum Advancement
C-39	Annual Death Benefits Questionnaire
C-59	Self-Insurer's Agreement as to Compensation on Account of Death
C-60	Injured Worker Statement for Reimbursement of Travel Expense
C-60-A	Injured Worker Reimbursement Rates for Travel Expense
C-77	Injured Worker's Change of Address Notification
C-84	Request for Temporary Total Compensation
C-86	Motion
C-92	Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability
C-94-A	Wage Statement
C-101	Authorization to Release Medical Information
C-108	WAIVER of Appeal Period
C-140	Initial Application for Wage Loss Compensation
C-141	Wage Loss Statement for Job Search
C-159	Waiver Of Workers’ Compensation Benefits For Recreational Or Fitness Activities
C-167-T	Objection to Tentative Order Awarding Permanent Partial Disability Compensation
C-230	Authorization to Receive Workers' Compensation Check
C-240	Settlement Agreement and Application for Approval of Settlement Agreement
FROI	First Report of an Injury, Occupational Disease or Death
MEDCO-31	Request for Prior Authorization of Medication Form
MEDCO-32	Request for Prior Authorization of NON-PREFERRED Medication Form
OD-58-22	Application for Adjustment of Claim in Case of Death Due to Occupational Disease
R-2	Injured Worker Authorized Representative
RH-1	Rehabilitation Agreement
RH-6	On-the-Job Training Agreement
RH-7	Loan/Release Agreement for Tool and Equipment
RH-10	Injured Worker's Record of Job Search Contacts
RH-24	Gradual Return to Work Contract Reimbursement Method
SI-28	Filing of Allegation Against a Self-Insured Employer
SI-42	Self Insured Joint Settlement Agreement and Release
SI-43	Acknowledgement of the Self-Insured Joint Settlement Agreement and Release