Forms and publications (2024)

{"data":[["s","s","s","s","s","s"],["Form code","Form name","Description","Audience","Purpose","Actions"],["300AP","Summary of Work-Related Injuries and Illness","Public employers must submit the master form to the Public Employment Risk Reduction Program by Feb. 1 for the previous calendar year.","Employers","Reporting","<a href=\"/forms-and-publications/summary-of-work-related-injuries-and-illnesses-300-ap\">Completeonline</a><br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/PERRPrecordkeepingforms.pdf\">ViewPDF</a> "],["A-112","Electronic Funds Transfer (EFT)/Direct Deposit Application for Authorized Representatives","Authorized representatives working with an injured worker should complete this form to get payments by direct deposit.","Workers","Compensation","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/A-112.pdf\">ViewPDF</a>"],["A-12","ACT Enrollment and Direct Deposit Authorization","Injured workers receiving disability benefits should complete this form to get payments by direct deposit.","Workers","Filing a claim","<a href=\"/forms-and-publications/act-enrollment-and-direct-deposit-authorization-a-12\">Completeonline</a> <br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/A-12.pdf\">ViewPDF</a>"],["A-21","Prepaid Debit Card Enrollment Application","Injured workers receiving permanent total disability benefits can have their benefit payments loaded directly onto a prepaid debit card.","Workers","Filing a claim","<a href=\"/forms-and-publications/prepaid-debit-card-enrollment-application-a-21\">Completeonline</a> <br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Workers/A-21.pdf\">ViewPDF</a>"],["A-35","Direct Deposit ACT Bank Change","Injured workers should use this form to change the bank where BWC deposits their compensation benefits.","Workers","Filing a claim","<a href=\"https://www.bwc.ohio.gov/worker/forms/A35/default.asp\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/A35.pdf\">ViewPDF</a>"],["AC-18","Labor Lease Transaction - Payroll","Description coming soon.","Employers","Reporting","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/AC-18.pdf\">ViewPDF</a>"],["AC-19","Labor Lease Transaction - Claims","Description coming soon.","Employers","Reporting","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/AC-19.pdf\">ViewPDF</a>"],["AC-2","Request to Add/Change or Terminate Permanent Authorization","Allows an employer or employer rep to authorize access to a company's policy and/or claims, change authorization access, or terminate access based on the type of representation requested.","Employers","Administration","<a href=\"https://www.bwc.ohio.gov/employer/PermanentAuthorization/Default.aspx\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/AC-02.pdf\">ViewPDF</a>"],["AC-28","Request to Charge the Surplus Fund or Non-at-Fault Motor Vehicle Accident","Details the required documentation a private or public employer taxing district must provide to support a request for experience modification calculation.","Employers","Compensation","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/AC-28.pdf\">ViewPDF</a>"],["AC-3","Temporary Authorization to Review Information","Employers should use this form to allow third party administrators to review and work on certain workers' compensation matters on their behalf.","Employers","Administration","<a href=\"/forms-and-publications/temporary-authorization-to-review-information-ac-3\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/AC-3.pdf\">ViewPDF</a>"],["AC-4","Request for Business Transfer Information","Employers seeking to acquire all or part of another business can use this form to request BWC to provide a limited release of information about the business that may be purchased.","Employers","Administration","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/AC-4.pdf\">ViewPDF</a>"],["C-101","Authorization to Release Medical Information","Injured workers should use this form to authorize the release of medical records relative to their work-related injury(s).","Workers \r\n<br>\r\nEmployers","Filing a claim","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-101.pdf\">ViewPDF</a>"],["C-108","Waiver of Appeal","Injured workers, employers and/or their respective representatives should use this form to waive appeal rights on a BWC or IC order.","Workers \r\n<br>\r\nEmployers","Waivers","<a href=\"/forms-and-publications/waiver-of-appeal-c-108\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-108.pdf\">ViewPDF</a>"],["C-11","ADR Appeal to the MCO Medical Treatment/Service Decision","Injured workers, employers, medical providers or authorized representatives should use this form to appeal the decision of the managed care organization (MCO) regarding treatment or services.","Workers \r\n<br>\r\nEmployers\r\n<br>\r\nProviders","Medical","<a href=\"/forms-and-publications/ADR-appeal-to-the-mco-medical-treatment-service-decision-c-11\">Completeonline</a><br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-11.pdf\">ViewPDF</a>"],["C-110","Employer/Employee Agreement to Select Ohio as the State of Exclusive Remedy for Workers' Compensation Claims","Employees and employers with an employment contract outside of Ohio who still want to receive Ohio workers' compensation coverage should complete this form.","Employers","General","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/C-110.pdf\">ViewPDF</a>"],["C-112","Employer/Employee Agreement to Select a State Other Than Ohio as the State of Exclusive Remedy for Workers' Compensation Claims","Employees and employers with an employment contract outside of Ohio who want to receive the other states' workers' compensation coverage should complete this form.","Employers","General","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/C-112.pdf\">ViewPDF</a>"],["C-140","Application for Wage Loss Compensation","Injured workers and the physician of record use this form to apply for compensation on wages lost due to a workplace injury or illness.","Workers","Wages","<a href=\"/forms-and-publications/application-for-wage-loss-compensation-c-140\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-140.pdf\">ViewPDF</a>"],["C-141","Wage Loss Statement for Job Search","Injured workers who already applied for or are receiving wage loss use this to document employers they contact during job searches and the results.","Workers","Wages","<a href=\"/forms-and-publications/wage-loss-statement-for-job-search-c-141\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-141.pdf\">ViewPDF</a>"],["C-142","Employer Report of Employee Earnings for Wage Loss Compensation","Employers or their authorized representatives use this form to supply BWC or the self-insuring employer with the injured worker's wage information.","Workers \r\n<br>\r\nEmployers","Wages","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-142.pdf\">ViewPDF</a>"],["C-143","Disability Evaluator Panel (DEP) Physician's Report of Work Ability Physical Conditions","Providers complete this form as they perform a clinical evaluation on the injured worker to capture their different physical capabilities and restrictions as a result of the workplace injury.","Providers","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-143.pdf\">ViewPDF</a>"],["C-143 PC","Disability Evaluator Panel (DEP) Physician's Report of Work Ability Cognitive/Psychological Conditions","Providers complete this form as they perform a clinical evaluation on the injured worker to capture their different cognitive/psychological abilities and limitations as a result of the workplace injury.","Providers","Medical","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-143PC.pdf\">ViewPDF</a>"],["C-159","Waiver of Workers' Compensation Benefits for Recreational or Fitness Activities","Employees who wish to waive their workers' compensation coverage to voluntarily participate in an employer-sponsored recreation or fitness activity should complete this form.","Workers \r\n<br>\r\nEmployers","Waivers","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-159.pdf\">ViewPDF</a>"],["C-17","Request for Injured Worker Outpatient Medication Reimbursem*nt","Injured workers should use this form to get reimbursed for prescribed outpatient medication only.","Workers \r\n<br>\r\nProviders","Medical","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-17.pdf\">ViewPDF</a>"],["C-174","Self-Insured Semiannual Report of Claim Payments","SI employers must complete one of these forms for each lost-time claim active during the six-month period or after an injured worker has returned to work if sooner than six months.","Employers","Reporting","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-174.pdf\">ViewPDF</a>"],["C-18","Notice to BWC of the Injured Worker and Employer Agreement and Authorization to Send Injured Worker's Check(s) to the Employer","Employers can use this form to establish an agreement between BWC, their injured workers, and themselves to be reimbursed for any wages they paid to their employees while they were receiving temporary total benefits from BWC.","Workers \r\n<br>\r\nEmployers","Compensation","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-18.pdf\">ViewPDF</a>"],["C-19","Service Invoice","Employers participating in the Transitional Work Grant Program must include this form when requesting reimbursem*nt.","Providers","Invoices","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-19.pdf\">ViewPDF</a>"],["C-190","Justification of Necessity or Seating/Wheeled Mobility","Providers complete this form to determine requirements for the injured worker, which is used by the managed care organization (MCO) to authorize wheeled mobility devices.","Providers","Medical","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-190.pdf\">ViewPDF</a>"],["C-196","Amptuation/Loss of Use Diagram","Providers use this form to mark the exact point of amputation/loss of use on the injured worker's hand(s).","Workers \r\n<br>\r\nProviders","Medical","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-196.pdf\">ViewPDF</a>"],["C-23","Notice to Change Physician of Record","Injured workers should use this form to notify their managed care organization (MCO) of a change of physician.","Workers","Medical","<a href=\"https://www.bwc.ohio.gov/worker/forms/c23/default.asp\">Completeonline</a><br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-23.pdf\">ViewPDF</a>"],["C-230","Authorization to Receive Workers' Compensation Check","Injured workers use this form to authorize BWC to send their workers' compensation checks to their attorneys or authorized representatives.","Workers","Compensation","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-230.pdf\">ViewPDF</a>"],["C-240","Settlement Agreement and Application for Approval of Settlement Agreement (for state-fund claims only)","Injured workers should use this form and get their employer to agree and sign to file for a claims settlement with BWC.","Workers \r\n<br>\r\nEmployers","Settlement","<a href=\"https://www.bwc.ohio.gov/bwccommon/forms/claimsettlement/default.asp\">Completeonline</a><br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-240.pdf\">ViewPDF</a>"],["C-242","Medical History and Disclosure","Injured workers (or their representative) complete this form to provide their medical history so BWC can determine an appropriate settlement value.","Workers","Settlement","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-242.pdf\">ViewPDF</a>"],["C-243","PTD-Death Settlement Acknowledgement and Waiver Full and Final Settlement","Injured workers receiving permanent total disability (PTD) benefits, requesting consideration of PTD benefits, or a claimant currently receiving death benefits should complete this form to request a settlement.","Workers","Settlement","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-243.pdf\">ViewPDF</a>"],["C-245","Indemnity Only Settlement Acknowledgement and Waiver","Injured workers applying for an indemnity only settlement should use this form when requesting a settlement.","Workers","Settlement","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-245.pdf\">ViewPDF</a>"],["C-255","Affidavit for Attorney Fees","Attorneys can use this form when requesting reimbursem*nt from BWC for fees owed to them from lump sum payments to injured workers.","Workers","General","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-255.pdf\">ViewPDF</a>"],["C-261","Workers' Compensation Claim Log","Injured workers' complete use this form to list details about their injury, workers' compensation claim, medical care, and return to work.","Workers","General","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-261.pdf\">ViewPDF</a>"],["C-262","Self-Insured Employer's Certification of Assignment After Initial Allowance","Self-insuring employers complete this form when they are accepting assignment of a claim that BWC or another party mistakenly assigned to another self-insuring employer.","Employers","Administration","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-262.pdf\">ViewPDF</a>"],["C-263","State-Fund Employer's Agreement to Accept Claim Assignment","State-fund employers complete this form when they are accepting assignment of a claim that BWC or another party mistakenly assigned to another state-fund employer.","Employers","Administration","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-263.pdf\">ViewPDF</a>"],["C-264","Request to Correct Employer and/or Policy Number Assignment","Employers complete this form when they allege BWC or another party incorrectly named them as the employer on a claim or assigned the claim to the incorrect policy number.","Employers","Administration","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-264.pdff\">ViewPDF</a>"],["C-265","Presumption of Causation for Firefighter Cancer","Firefighters who have served at least six years of hazardous duty and contract cancer can use this form to potentially receive benefits. ","Workers","Medical","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-265.pdf\">ViewPDF</a>"],["C-267","Request for Changes Related to BWC Representative ID Number","Employers use this form to request changes related to their BWC representative ID number.","Workers","Administration","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Workers/C-267.pdf\">ViewPDF</a>"],["C-30","Request for Medical Information","Injured workers and employers can use this form to get additional information about a workplace injury from a particular physician.","Workers \r\n<br>\r\nEmployers\r\n<br>\r\nProviders","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-30.pdf\">ViewPDF</a>"],["C-32","Application for Payment of Lump Sum Advancement","Injured workers or their dependents should use this form to request an advanced payment of their workers' compensation benefits.","Workers","Compensation","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-32.pdf\">ViewPDF</a>"],["C-5","Application for Death Benefits and/or Funeral Expenses","This form is used to supply BWC with additional information when benefits are being requested on account of the death of an injured worker.","Workers","Compensation","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-5.pdf\">ViewPDF</a>"],["C-512","Notice of Intent to Settle","Injured workers or employers can use this form to extend the court appeal deadline for an Ohio workers' compensation claim from 60 days to 150 days.","Workers \r\n<br>\r\nEmployers","Settlement","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-512.pdf\">ViewPDF</a>"],["C-55","Salary Continuation Agreement","Employers can use this form to acknowledge an agreement between themselves and an employee to pay salary/wage continuation in lieu of temporary total or living maintenance compensation.","Employers","Compensation","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-55.pdf\">ViewPDF</a>"],["C-59","Self-Insurer's Agreement as to Compensation on Account of Death","The self-insuring employer submits this form to BWC or the IC when it determines the beneficiary or beneficiaries and the benefit rate(s) to be paid as a result of a death due to an injury.","Employers","Compensation","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-59.pdf\">ViewPDF</a>"],["C-6","Application for Accrued Compensation","Those eligible for benefits after an injured worker's death can use this form to apply for compensation that was unpaid at the time of the decedent's death.","Workers","Compensation","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-6.pdf\">ViewPDF</a>"],["C-60","Injured Worker Statement for Reimbursem*nt of Travel Expenses","Injured workers use this form to request reimbursem*nt for travel expenses incurred relative to a medical exam or treatment for a work-related injury or disease.","Workers","Travel reimbursem*nt","<a href=\"https://www.bwc.ohio.gov/worker/forms/c60/default.asp\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-060.pdf\">ViewPDF</a>"],["C-60-A","Injured Worker Reimbursem*nt Rates for Travel Expenses","A companion to the C-60, this form explains the reimbursable rates for travel-related expenses.","Workers","Travel reimbursem*nt","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-60A.pdf\">ViewPDF</a>"],["C-72","Consent to Release Information","Injured workers can use this form to request that BWC releases information about their claim with another individual or organization.","Workers","Filing a claim","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-72.pdf\">ViewPDF</a>"],["C-77","Injured Worker's Change of Address Notification","Injured workers use this form to notify BWC or their self-insuring employer of a new address and phone number.","Workers","Administration","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-077.pdf\">ViewPDF</a>"],["C-84","Request for Temporary Total Compensation","Injured workers must use this form to initiate or extend payment of temporary total disability benefits.","Workers","Temporary total/Salary continuation","<a href=\"/forms-and-publications/request-for-temporary-total-compensation-c-84\">Completeonline</a><br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/c-84.pdf\">ViewPDF</a>"],["C-86","Motion","Any party to the claim can use this form to request action on a claim from either BWC or Ohio’s Industrial Commission (IC).","Workers \r\n<br>\r\nEmployers","General","<a href=\"/forms-and-publications/motion-c-86\">Completeonline</a><br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-86.pdf\">ViewPDF</a>"],["C-9","Request for Medical Service Reimbursem*nt or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease","Medical providers use this form to supply information to managed care organizations (MCOs) or self-insuring employers and to request authorization for additional treatment.","Employers\r\n<br>\r\nProviders","Medical","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-9.pdf\">ViewPDF</a>"],["C-9-A","Request for Additional Medical Documentation for C-9","Medical providers use this form to supply additional information upon request such as progress notes/office notes, emergency room reports, operative reports, discharge summaries, etc.","Providers","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-9-A.pdf\">ViewPDF</a>"],["C-9-A Psych","Request for Additional Medical Documentation for C-9 for Psychological Services","Medical providers use this form to supply additional information upon request such as duration of previous authorized treatment, missed counseling appointments, medication, etc.","Providers","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/C-9-APsych.pdf\">ViewPDF</a>"],["C-92","Application for Determination or Increase of Permanent Partial Disability","Injured workers should use this form to request an award for permanent impairment, either physical or psychological, resulting from an allowed workers' compensation claim.","Workers","Percentage of permanent partial","<a href=\"/forms-and-publications/application-for-determination-or-increase-of-pp-disability-c-92\">Completeonline</a><br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/C-92.pdf\">ViewPDF</a>"],["CHP-4A","Application for Disability Relief","Employers use this form to apply to have all or part of an injured workers' claims costs charged to the statutory surplus fund.","Employers","Compensation","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/CHP-4A%20rv1201.pdf\">ViewPDF</a>"],["CIRP-1","Application for Claim Impact Reduction Program","Eligible, private, state-fund employers and public employer taxing districts can use this form to apply for the program.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/employer/forms/OCPApplication/Default.aspx\">Completeonline</a> <br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/CIRP-1.pdf\">ViewPDF</a>"],["COVER","Medical Documentation Fax Cover Sheet","Description coming soon.","Providers","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MedRepFaxCvrSht.pdf\">ViewPDF</a>"],["DFSP-1","DFSP Accident Report","Employers participating in the Drug-Free Safety Program (DFSP) are required to submit an Accident Report for each injury or illness claim it files with BWC. ","Employers","Reporting","<a href=\"https://www.bwc.ohio.gov/employer/forms/dfsp/accidentreport/default.aspx\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/DFSP-1.pdf\">ViewPDF</a>"],["DFSP-3","Drug-Free Safety Program (DFSP) Annual Report - Basic and Advanced Levels","Employers participating in the Drug-Free Safety Program are required to submit an annual report. ","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/employer/forms/dfsp/annualreport3/default.aspx\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/DFSP-3Sample.pdf\">ViewPDF</a>"],["DFSP-4","Drug-Free Safety Program (DFSP) Annual Report - Comparable Program Only","Employers participating in a comparable drug-free program are required to submit an annual report.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/employer/forms/dfsp/annualreport4/default.aspx\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/DFSP-4Sample.pdf\">ViewPDF</a>"],["DFSP-5","DFSP Safety Action Plan","Employers participating at the Advanced level of the Drug-Free Safety Program (DFSP) must complete and submit this form within 60 days of the start of each program year.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/employer/forms/dfsp/actionplan/default.aspx\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/DFSP-5.pdf\">ViewPDF</a>"],["DFSP-6","Application for the Drug-Free Safety Program Vendor Directory","Vendors who wish to apply for the directory or update their information on the directory should complete this form.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/DFSP-6.pdf\">ViewPDF</a>"],["ECP-TX","Physician's Treatment Request","Physicians use this form to submit a treatment plan for an injured worker under the Enhanced Care Program.","Providers","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/ECP-TX.pdf\">ViewPDF</a>"],["FROI","First Report of an Injury, Occupational Disease or Death","Injured workers, employers, or medical providers use this form to initiate a workers compensation claim. ","Workers","Filing a claim","<a href=\"/forms-and-publications/froi\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/FROI-20020723.pdf\">ViewPDF</a>"],["IC-12","Ohio Industrial Commission Notice of Appeal","Injured workers or employers can use this form to appeal a claim decision to the Industrial Commission (IC) of Ohio.","Employers","Appeals","<a href=\"https://www.ic.ohio.gov/forms/forms/ic12.pdf\">ViewPDF</a>"],["IC-167-T","Objection to Tentative Order Awarding Permanent Partial Disability Compensation ","Injured workers, employers, and/or authorized representatives use this form to file an objection to a BWC tentative order determining the percentage of permanent partial disability compensation.","Workers \r\n<br>\r\nEmployers","Percentage of permanent partial","<a href=\"https://www.ic.ohio.gov/forms/forms/ic_167_t.pdf\">ViewPDF</a>"],["IC-2","Application for Compensation for Permanent Total Disability","Injured workers who wish to apply for Permanent Total Disability benefits must submit this form and all medical evidence to their local IC office.","Workers \r\n<br>\r\nProviders","Compensation","<a href=\"https://www.ic.ohio.gov/forms/forms/ic2.pdf\">ViewPDF</a>"],["IC-GC1","Agreement as to Compensation for Permanent Partial Disability","The injured worker and self-insuring employer use this form when they have entered into an agreement for compensation of permanent partial disability.","Workers \r\n<br>\r\nEmployers","Percentage of permanent partial","<a href=\"https://www.ic.ohio.gov/forms/forms/icgc1.pdf\">ViewPDF</a>"],["LEGAL-15","Application for Adjudication Hearing","Employers or their representatives use this form to request a decision by the Adjudicating Committee on the employer's protest that the employer and appropriate BWC business unit have not resolved.","Employers","Appeals","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/LEGAL-15.pdf\">ViewPDF</a>"],["LEGAL-16","Settlement Application for Non-Complying Employer Claims","Employers and their authorized representatives can use this form to request a decision from the Adjudicating Committee to settle non-compliance liability to the state insurance fund.","Employers","Settlement","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/LEGAL-16.pdf\">ViewPDF</a>"],["MEDCO-12","Request to Change Provider Information","Providers use this form to update their information, enrollment data, tax identification numbers, and group affiliations.","Providers","Administration","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-12.pdf\">ViewPDF</a>"],["MEDCO-13","Application for Provider Enrollment and Certification","Providers use this form if they wish to become part of BWC's provider network and are required to become BWC certified.","Providers","Administration","<a href=\"/forms-and-publications/application-for-provider-enrollment-and-certification-medco-13\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-13.pdf\">ViewPDF</a>"],["MEDCO-13A","Application for Provider Enrollment Non-Certification","Providers use this form if they wish to become part of BWC's provider network and are not required to become BWC certified.","Providers","Administration","<a href=\"/for-providers/provider-forms/application-for-provider-enrollment-non-certification-(MEDCO-13A)\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-13a.pdf\">ViewPDF</a>"],["MEDCO-13B","Application for Provider Recertfication","Providers use this form when they need to complete the recertification process with BWC.","Providers","Administration","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Providers/MEDCO-13B.pdf\">ViewPDF</a>"],["MEDCO-14","Physician's Report of Work Ability","Providers of record use this form to certify an injured worker is temporarily and totally disabled due to a work injury or to identify work abilities when worker capabilities are restricted due to the work injury.","Workers \r\n<br>\r\nProviders","Temporary total/Salary continuation","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-14.pdf\">ViewPDF</a>"],["MEDCO-15","Non-Certified Enrollment Application","MCOs use this form to enroll providers who are currently not in the BWC provider system or to reactivate enrollment for inactive providers.","MCOs","Administration","<a href=\"/for-providers/provider-forms/non-certified-enrollment-app-MEDCO-15\">Completeonline</a> "],["MEDCO-16","Mental Health Notes Summary","Providers use this form to submit mental health notes for an injured worker to BWC/MCOs or a self-insuring employer.","Providers","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-16.pdf\">ViewPDF</a>"],["MEDCO-17","Transitional Work Grant Program Job Analysis Template Form","BWC accredited transitional work developers or providers use this form to identify essential job functions, describe physical demands of required tasks, work conditions, knowledge, and skilled experience needed to perform job analyses.","Providers","Return to work","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Providers/MEDCO-17.pdf\">ViewPDF</a>"],["MEDCO-17S","Supplemental Job Analysis Template Forms","BWC accredited transitional work developers or providers use this form as a supplement to MEDCO-17 when more than five essential job tasks are identified.","Providers","Return to work","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Providers/MEDCO-17S.pdf\">ViewPDF</a>"],["MEDCO-22","Medication Physician Review","Description coming soon.","Providers","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-22.pdf\">ViewPDF</a>"],["MEDCO-30","Disability Evaluator Application","Providers interested in becoming a member of BWC's Disability Evaluators Panel should complete this application.","Providers","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-30.pdf\">ViewPDF</a>"],["MEDCO-31","Request for Prior Authorization of Medication","Injured workers' physicians use this form to request prior authorization for medications not typically used for industrial injuries or occupational diseases.","Workers \r\n<br>\r\nProviders","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-31.pdf\">ViewPDF</a>"],["MEDCO-34","MCO Request for Drug Utilization Review","Description coming soon.","MCOs\r\n<br>\r\nProviders","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-34.pdf\">ViewPDF</a>"],["MEDCO-35","Formulary Medication Request Form","Physicians use this form to ask the Pharmacy & Therapeutics Committee to consider adding a particular drug to the formulary.","Providers","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-35.pdf\">ViewPDF</a>"],["MEDCO-38","Certification Agreement Between the Injured Worker and Service Provider (Contractor)","Description coming soon.","Workers \r\n<br>\r\nProviders","Administration","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-38.pdf\">ViewPDF</a>"],["MEDCO-43","Caregiver Services Physician's Evaluation Report","Providers use this form to report their evaluation of the injured worker's condition and their need for continued caregiver services.","Providers","Medical","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Providers/MEDCO-43.pdf\">ViewPDF</a>"],["MEDCO-6","Waiver of Examination Statewide Disability Evaluation System","BWC claims service specialists use this form to obtain agreement from employers to waive the legally mandated 90-day exam.","Employers","Waivers","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-6.pdf\">ViewPDF</a> "],["MEDCO-8","Self-Insured Employer/Injured Worker Screening","A self-insuring employer uses this form to request a statewide disability screening examination for injured workers who have received 90 consecutive days of temporary total disability compensation.","Employers","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-8.pdf\">ViewPDF</a> "],["N/A","2024 scheduled payment dates for PTD and death benefits only","A schedule to inform recipients of permanent total disability (PTD) and death benefits of the scheduled payment dates for the year 2024.","Workers","Compensation","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Workers/PensionCalendar.pdf\">ViewPDF</a> "],["N/A","Abatement Verification Report","Employers can use this form to document and verify that identified workplace safety hazards have been corrected and that the workplace now complies with safety regulations.","Employers","Administration","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/avreport.pdf\">ViewPDF</a> "],["N/A","Absorption rates for overpayment chart","This chart provides a reference for calculating the absorption rate when there has been an overpayment of workers' compensation benefits.","BWC\r\n<br>\r\nWorkers \r\n<br>\r\nEmployers","Compensation","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Workers/AbsorbRatesforOverpay.pdf\">ViewPDF</a> "],["N/A","BWC Implementation Invoice","Service providers and vendors can use this form to invoice for services related to the implementation of a BWC program or initiative.","Employers","Invoices","<a href=\"\">Downloaddocument</a> "],["N/A","BWC Service Invoice","Service providers can use this form to charge for their services related to workers' compensation claims, such as medical treatments, vocational rehabilitation, or other support services provided to injured workers.","Employers","Invoices","<a href=\"\">Downloaddocument</a> "],["N/A","BWC Subrogration Referral Form"," Employers, MCOs, and their representatives can use this form to make subrogation referrals. ","Employers \r\n<br>\r\nProviders","Referral","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/SubroRefer.pdf\">ViewPDF</a> "],["N/A","Certification safety agreement for sponsors and affiliate sponsors","Sponsoring and affiliate organizations can use this form certify that they will provide their members with information and assistance on workplace safety.","Employers","Safety","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/SponsorCertforSafety.pdf\">ViewPDF</a> "],["N/A","Compensation rates","This document provides the current rates of compensation for various types of workers' compensation benefits.","BWC\r\n<br>\r\nWorkers \r\n<br>\r\nEmployers","Compensation","<a href=\"/static/Workers/CompRates.pdf\">ViewPDF</a> "],["N/A","Customer service office triage assignment and contact information","This document provides the contact details and assignments of customer service representatives who handle different types of inquiries and cases.","BWC","Administration","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/ServiceOfficeTriageAssign.xlsx\">Downloaddocument</a> "],["N/A","Instructions for completing the Standard Authorization Form","Individuals or their representatives can use this form to give consent to the release of personal health information.","Workers","Medical","<a href=\"https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/Resources/Publications/Forms/ODM10221i.pdf\">ViewPDF</a> "],["N/A","MCO Selection Form","State-fund employers must select a managed care organization (MCO) or BWC may assign one to them.","Employers","Administration","<a href=\"/forms-and-publications/mco-selection\">Completeonline</a> <br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/SelectionForm.pdf\">ViewPDF</a>"],["N/A","Net present value factors chart","This chart is used to provide factors for calculating the net present value of future workers' compensation payments.","BWC\r\n<br>\r\nWorkers","Settlement","<a href=\"/static/forms/NPV2021.xls\">Downloaddocument</a> "],["N/A","OSHA On-Site Consultation Request Form","Small to medium, high hazard private employers can use this form to request for OSHA On-site Consultation program for safety and health assistance.","Employers","Safety","<a href=\"/for-employers/safety-and-training/safety-consultations/osha-on-site-consultation-request-form\">Completeonline</a> "],["N/A","PERRP Compliance Assistance Request","Employers can use this form to request PERRP compliance assistance services that provide risk reduction inspections, industrial hygiene sampling, written program/policy reviews, and training.","Employers","Safety","<a href=\"/for-employers/safety-and-training/safety-consultations/perrp-request\">Completeonline</a> "],["N/A","PTD rate calculation worksheet instructions","A guide on the process of calculating the rate of compensation for permanent total disability benefits.","Workers","Compensation","<a href=\"/static/Providers/PTDRateCalculationWorksheetInstructions.doc\">Downloaddocument</a> "],["N/A","PTD rate calculation worksheet","Employers, injured workers, or their representatives can use this worksheet to compute the amount of PTD benefits based on relevant wage data and compensation rules.","Workers","Compensation","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/PTDRateCalculationWorksheet.xlsm\">Downloaddocument</a> "],["N/A","Reporting fraud","Providers can use this form to report workers' compensation fraud.","Employers","Fraud","<a href=\"https://www.bwc.ohio.gov/bwccommon/forms/Fraud/default.aspx\">Completeonline</a> "],["N/A","Request for safety and health consultation form","Employers can use this form to request for safety and health consultations to help develop strategies that will reduce risk of injury or illness for employees.","Employers","Safety","<a href=\"/for-employers/safety-and-training/safety-consultations/safety-form\">Completeonline</a> "],["ODM-10221","Standard Authorization Form","Complete this form to authorize the release of protected health information (PHI) and other personal information.","Workers","Medical","<a href=\"https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/Resources/Publications/Forms/ODM10221fillx.pdf\">ViewPDF</a> "],["PERRP-5","Safety and Health Complaint Responses - Public Employment Risk Reduction Program","Employers should complete this form to document and track responses of safety and health complaints filed by public employees or their representatives.","Employers","Administration","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/crespond.pdf\">ViewPDF</a> "],["PERRP-7","PERRP Fatality Reporting Form","Employers should complete this form if a workplace fatality has occurred and must be reported within eight hours.","Employers","Reporting","<a href=\"/for-employers/safety-and-training/safety-consultations/fatality-reporting-online-form-perrp-7\">Completeonline</a> "],["PERRP-8","PERRP Serious Injury Reporting Form","Employers should complete this form if a severe workplace injury has occurred resulting in hospitalization, amputation, or eye loss and must be reported within 24 hours.\r\n","Employers","Reporting","<a href=\"/for-employers/safety-and-training/safety-consultations/serious-injury-reporting-online-form-perrp-8\">Completeonline</a> "],["R-1","Authorization of Representative of Employer","Employers can use this form to designate an authorized representative for workers' compensation claims.","Employers","Filing a claim","<a href=\"/forms-and-publications/authorization-of-representative-of-employer-r-1\">Completeonline</a> <br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/r-1.pdf\">ViewPDF</a>"],["R-2","Claimant Authorized Representative","Injured workers and their representatives can use this form to notify BWC of the injured worker's representative.","Workers","Filing a claim","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/r-2.pdf\">ViewPDF</a> "],["R-4","Application for Representative Identification Number (RIN)","After receiving a RIN number an employer or injured worker can use this form to assign a representative to an individual claim.","Workers \r\n<br>\r\nEmployers","Administration","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/R-4.pdf\">ViewPDF</a> "],["RH-1","Rehabilitation Agreement","A vocational rehabilitation case manager uses this form to obtain agreement from an injured worker to participate in vocational rehab services.","Workers \r\n<br>\r\nProviders","Treatment/Return to work","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Providers/RH-1.pdf\">ViewPDF</a> "],["RH-10","Vocational Rehabilitation Plan Job Search Contacts","Injured workers can use this form to record job search contacts when participating in job-search rehab plans. ","Workers","Treatment/Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-10.pdf\">ViewPDF</a> "],["RH-13","Work Trial Agreement","Employers should use this form to formalize a work trial agreement between the injured worker, BWC, and them so that the worker can demonstrate their ability to perform a job.","Employers \r\n<br>\r\nProviders","Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-13.pdf\">ViewPDF</a> "],["RH-14","Job Modification Agreement - Supplier Reimbursem*nt","Employers should use this form to formalize an agreement between the injured worker, BWC, and them regarding job modifications or accommodations that may require specialized equipment, tools or changes to the work environment.","Employers \r\n<br>\r\nProviders","Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-14.doc\">DownloadDOC</a> "],["RH-15","Job Modification Agreement - Return-to-Work (RTW) Employer","Employers should use this form to formalize an agreement between the injured worker, BWC, and them regarding job modifications or accommodations needed for the worker to return to work after a workplace injury.","Employers \r\n<br>\r\nProviders","Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-15.doc\">DownloadDOC</a> "],["RH-18","Authorization for Living Maintenance Wage Loss","Injured workers can use this form to set up living maintenance wage loss payments with BWC. ","Workers","Wages","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-18.pdf\">ViewPDF</a> "],["RH-19","Employer Incentive Contract","A vocational rehabilitation case manager uses this form when writing a rehab plan that involves an incentive for the employer. ","Employers \r\n<br>\r\nProviders","Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-19.pdf\">ViewPDF</a> "],["RH-21","Vocational Rehabilitation Closure Report","A vocational rehabilitation case manager uses this form to close the vocational rehab portion of a claim. ","Providers","Treatment/Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-21.pdf\">ViewPDF</a> "],["RH-24","Gradual Return to Work Agreement","A vocational rehabilitation case manager uses this form when writing a rehab plan that involves returning the injured worker back to work gradually.","Workers \r\n<br>\r\nEmployers\r\n<br>\r\nProviders","Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-24.pdf\">ViewPDF</a> "],["RH-42","Vocational Rehabilitation Initial Assessment Report","A vocational rehabilitation case manager uses this form to outline the rehabilitation goals and plan for an injured worker who is participating.","Providers","Treatment/Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-42.doc\">DownloadDOC</a> "],["RH-43","Vocational Rehabilitation Assessment Plan","A vocational rehabilitation case manager uses this form to evaluate and document the transferable skills of an injured worker.","Providers","Treatment/Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-43.doc\">DownloadDOC</a> "],["RH-44","Vocational Rehabilitation Comprehensive Plan","A vocational rehabilitation case manager uses this form to conduct a survey of the labor market to identify potential job opportunities suitable for an injured worker.","Providers","Treatment/Return to work","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Providers/RH-44.pdf\">ViewPDF</a> "],["RH-45","Authorization Request for Vocational Rehabilitation Plan","A vocational rehabilitation case manager uses this form to document efforts made to place an injured worker in suitable employment.","Providers","Treatment/Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-45.doc\">DownloadDOC</a> "],["RH-46","Vocational Rehabilitation Progress Report","An injured worker with assistance from a vocational rehabilitation case manager uses this form to request a voucher for training, education, or job placement services under Ohio's workers' compensation system.","Providers","Treatment/Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-46.doc\">DownloadDOC</a> "],["RH-47","Vocational Rehabilitation Job Retention Plan","Providers or vendors use this form to submit invoices for payment related to vocational rehabilitation services provided to an injured worker under a voucher program.","Providers","Treatment/Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-47.doc\">DownloadDOC</a> "],["RH-5","Employer/Trainer's Report","Employers can use this form to provide information to the vocational rehabilitation case manager concerning an injured worker's progress in an on-the-job training plan.","Employers \r\n<br>\r\nProviders","Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-5.pdf\">ViewPDF</a> "],["RH-6","On-the-Job Training Agreement","The vocational case rehabilitation manager uses this form when writing a rehab plan that involves on-the-job training.","Workers \r\n<br>\r\nEmployers\r\n<br>\r\nProviders","Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-6.pdf\">ViewPDF</a> "],["RH-7","Loan/Release Agreement for Tools and Equipment","The vocational rehabilitation case manager uses this form when purchasing tools or equipment for an injured worker as part of a rehab plan. ","Workers\r\n<br>\r\nMCOs","Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-7.pdf\">ViewPDF</a> "],["RH-8","Vocational Rehabilitation Closure Report - Addendum","Our disability management coordinators and/or the managed care organizations (MCOs) use this form when there is a difference of opinion with the field case manager's justification for closure.","MCOs\r\n<br>\r\nBWC","Treatment/Return to work","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-8.pdf\">ViewPDF</a> "],["RH-94A","Report of Earnings for Living Maintenance Wage Loss Compensation","A vocational rehabilitation case manager uses this form to document the earnings of an injured worker while they are undergoing rehabilitation.","Workers \r\n<br>\r\nProviders","Wages","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/RH-94A.pdf\">ViewPDF</a> "],["RPS-Amend P/R","Amended True-Up Payroll Report","Employers can use this form to correct errors or omissions in previously filed payroll reports, ensuring accurate calculation of workers' compensation premiums.","Employers","Reporting","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/PayrollAmend.pdf\">ViewPDF</a> "],["SH-12","Sharps Injury Form - Needlestick Report","Public employers must complete and submit this form within 10 business days for every needlestick or sharps injury to the Public Employer Risk Reduction Program.","Employers","Reporting","<a href=\"https://www.bwc.ohio.gov/employer/forms/SHARPSInjuryReport/Default.aspx\">Completeonline</a> <br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/SH-12.pdf\">ViewPDF</a>"],["SH-2","Division of Safety & Hygiene Group-Experience- and Group-Retrospective-Rating Safety Requirements Annual Report"," Employers participating in group-rating programs can use this form to report on the safety requirements and activities.","Employers","Reporting","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/SH-2.pdf\">ViewPDF</a> "],["SH-26","Safety Management Self-Assessment","Employers who want to participate in incentive programs must complete this form that will help them evaluate their safety and claims management systems, and identify opportunities for improvement.","Employers","Safety","<a href=\"https://www.bwc.ohio.gov/employer/forms/SafetyMgtSelfAssessment/Default.aspx\">Completeonline</a> <br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/SH-26.pdf\">ViewPDF</a>"],["SH-6","PERRP Complaint Form","Public employees or their representatives can use this form to report hazards or unsafe conditions in their workplace, prompting an investigation by the BWC.","Workers \r\n<br>\r\nEmployers","Safety","<a href=\"/for-employers/safety-and-training/safety-consultations/perrp6\">Completeonline</a> <br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/SH-6.pdf\">ViewPDF</a>"],["SI-16","Claims Liability Agreement","Self-insuring employers can use this form to document the agreement between BWC and them regarding the handling of workers' compensation claims.","Employers","Self-insurance","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/SI-16.pdf\">ViewPDF</a> "],["SI-28","Filing of Allegation Against a Self-Insured Employer","Injured workers can use this form to file complaints against self-insuring employers for issues like incorrect compensation rates or unpaid medical bills.","Workers \r\n<br>\r\nEmployers","Self-insurance","<a href=\"/forms-and-publications/filing-of-allegation-against-a-self-insured-employer-si-28\">Completeonline</a> <br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/SI-28.pdf\">ViewPDF</a>"],["SI-38","Unconditional and Continuing Guarantee","Parent companies or third parties can use this form to provide a financial guarantee for the obligations of a self-insuring employer.","Employers","Self-insurance","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/SI-38.pdf\">ViewPDF</a> "],["SI-40","Report of Paid Compensation and Case Reserves","Self-insuring employers can use this form to report the compensation paid and reserves set aside by them for workers' compensation claims.","Employers","Reporting","<a href=\"https://www.bwc.ohio.gov/employer/services/PaidCompensation/PaidCompReporting/ReportPaidCompensation.aspx\">Completeonline</a> <br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/SI-40.pdf\">ViewPDF</a>"],["SI-42","Self-Insured Joint Settlement Agreement and Release","This form sets out the terms of a lump sum settlement between an injured worker and self-insuring employer.","Workers \r\n<br>\r\nEmployers","Settlement","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/SI-42.pdf\">ViewPDF</a> "],["SI-43","Acknowledgement of the Self-Insured Joint Settlement Agreement and Release","The Injured worker and self-insuring employer can use this form to acknowledge their agreement to the lump sum settlement.","Workers","Settlement","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/SI-43.pdf\">ViewPDF</a> "],["SI-44","Election to Withdraw from Claims Reimbursem*nt Fund","Self-insuring employers can use this form to withdraw from the claims reimbursem*nt fund.","Employers","General","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/SI-44.pdf\">ViewPDF</a> "],["SI-50","Self-Insured Construction Wrap-Up Application","Construction project owners or general contractors can use this form to cover all subcontractors under a single workers' compensation policy, simplifying administration and potentially reducing costs.","Employers","Administration","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/SI-50.pdf\">ViewPDF</a> "],["SI-51","Application for Certification of Qualified Health Plan (QHP)","Health plan providers can use this form to ensure their plan meets the standards and requirements set by the BWC for providing medical care to injured workers.","Employers","Medical","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/SI-51.pdf\">ViewPDF</a> "],["SI-52","Self-Insured Claims Reimbursem*nt (Sysco) Application","Self-insuring employers participating in the Sysco program can use this form to seek reimbursem*nt for large claims that exceed a specified threshold, providing financial relief for catastrophic losses.","Employers","Compensation","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/SI-52.pdf\">ViewPDF</a> "],["SI-6","Initial Application by Employer for Authority to Pay Compensation Etc., Directly","Employers can use this form to seek approval from the BWC to directly pay workers' compensation benefits and manage claims, rather than purchasing insurance through the state fund.","Employers","Self-insurance","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/SI-6.pdf\">ViewPDF</a> "],["SI-7","Application for Renewal of Authorization to Operate as a Self-Insured Policy"," Self-insuring employers can use this form to indicate their continuance of self-insurance each year.","Employers","Self-insurance","<a href=\"https://www.bwc.ohio.gov/employer/forms/sirenewal/Default.aspx\">Completeonline</a> "],["SUR-1","Substance Use Recovery and Workplace Safety Program Enrollment Form","Employers can use this form to participate in a program aimed at addressing substance use issues in the workplace, providing resources for prevention, treatment, and recovery.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/employer/SURWSP/Default.aspx\">Completeonline</a> "],["SUR-2","Substance Use Recovery and Workplace Safety Program Request for Reimbursem*nt","Employers participating in this program can use this form to get reimbursed for costs incurred in implementing substance use recovery and workplace safety measures.","Employers","Programs","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/SUR-2.pdf\">ViewPDF</a> "],["SUR-3","Substance Use Recovery and Workplace Safety Program Agreement","Employers can use this form to formalize the agreement between BWC and them for participation in the Substance Use Recovery and Workplace Safety Program.","Employers","Programs","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/SUR-3.pdf\">ViewPDF</a> "],["TWB-1","Application for Transitional Work Bonus Program","Employers can use this form to apply for the Transitional Work Bonus program which offers a back-end bonus of up to 10% of the employer's pure premium.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/employer/forms/TransitionalWork/bonus/Default.aspx\">Completeonline</a><br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/TWB-1.pdf\">ViewPDF</a> "],["TWB-2","Transitional Work Offer and Acceptance Form","Employers participating in the Transitional Work Bonus program must complete this form for every offer of transitional work they make for claims with a date of injury during the bonus period. ","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/employer/forms/TransitionalWork/offer/Default.aspx\">Completeonline</a><br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/TWB-2.pdf\">ViewPDF</a> "],["TWD-115","Transitional Work Developer's Application","Professionals or organizations can complete this form if they are seeking to become accredited transitional work developers.","Providers","Treatment/Return to work","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Providers/TWD-115.pdf\">ViewPDF</a> "],["TWD-116","Transitional Work Developer's Reaccreditation Application","Transitional work developers who are already accredited can use this form to renew or maintain their accreditation with BWC.","Providers","Treatment/Return to work","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Providers/TWD-116.pdf\">ViewPDF</a> "],["TWG-1","Application for Transitional Work Grant Program","Employers can use this form to apply for funds to help them contract with BWC-accredited transitional work developers to establish a transitional work program in their workplace.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/employer/forms/TransitionalWork/grant/Default.aspx\">Completeonline</a><br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/TWG-1.pdf\">ViewPDF</a> "],["TWG-2","Transitional Work Grant Reimbursem*nt Request Form","Employers participating in the Transitional Work Grant Program can use this form along with the service invoice and grant agreement to request reimbursem*nt from their grant fund.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/TWG-2.pdf\">ViewPDF</a> "],["TWG-3","Transitional Work Grant Agreement","Employers participating in the Transitional Work Grant Program must sign this agreement and include it when they request reimbursem*nt.","Employers","Programs","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/TWG-3.pdf\">ViewPDF</a> "],["TWG-4","Transitional Work Grant Program Corporate Analysis Questionnaire Work Sheet","Employers and transitional work developers should complete this form with the employer's grant plan in lieu of a written corporate analysis narrative.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/TWG-4.pdf\">ViewPDF</a> "],["U-108","Opt Out of .99 EM Construction Cap Program","Eligible construction industry employers must complete and return this agreement to BWC by September 30th of the rating year of participation to officially state their intention to opt out of the program. ","Employers","General","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/U-108.pdf\">ViewPDF</a> "],["U-114","Request to Cancel Workers' Compensation Coverage","Employers can use this form to formally request the cancellation of their workers' compensation insurance policy with the BWC.","Employers","Coverage","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-114.pdf\">ViewPDF</a> "],["U-115","Request to Transfer Existing Coverage to Succeeding Employer","Succeeding employers can use this form if they wish to maintain the existing policy of the predecessor employer and it must be signed by both parties.","Employers","Coverage","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-115.pdf\">ViewPDF</a> "],["U-116","Notification to Add/Remove an Aditional Named Insured(s)","You can use this form is to request the addition or removal of an Additional Named Insured. ","Employers","Administration","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-116.pdf\">ViewPDF</a> "],["U-117","Notification of Policy Update","Employers should use this form to notify BWC of demographic changes to the information on their workers' compensation policies. ","Employers","Administration","<a href=\"/forms-and-publications/notification-of-policy-update-u-117\">Completeonline</a> <br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-117.pdf\">ViewPDF</a> "],["U-118","Notification of Business Acquisition/Merger or Purchase/Sale","Employers should use this form to send notice to BWC when an existing business was acquired or purchased.","Employers","Administration","<a href=\"https://www.bwc.ohio.gov/employer/forms/purchasesale/default.aspx\">Completeonline</a><br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-118.pdf\">ViewPDF</a> "],["U-131","Notice of Election to Obtain Coverage from Other States for Employees Working Outside of Ohio","Employers should complete this form, when they have employees working temporarily in other states and have obtained the other states' coverage, to elect payroll segregation for work performed outside of Ohio.","Employers","Coverage","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-131.pdf\">ViewPDF</a> "],["U-140","Application for Drug-Free Safety Program","Employers should use this form as it offers a rate reduction to employers addressing workplace use, misuse and abuse of alcohol and other drugs within the context of the company's holistic safety efforts.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/employer/forms/dfsp/u140/default.aspx\">Completeonline</a> <br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/U-140.pdf\">ViewPDF</a> "],["U-145","Lump Sum Settlement (LSS) Direct Reimbursem*nt Rating and Payment Program for Public Employer State Agencies","Employers should use this form to apply for the LSS Program which is reserved for public employer state (PES) agencies that are not currently participating in a settlement payment program. ","Employers","Settlement","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/U-145.pdf\">ViewPDF</a> "],["U-147","Non-Ohio Amended Payroll Report","Employers with employees working outside of Ohio can use this form to correct payroll information that affects their workers' compensation premium calculations.","Employers","Reporting","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-147.pdf\">ViewPDF</a> "],["U-148","Application for Deductible Program","Employers should use this form to apply for the Deductible Program which allows employers to pay per claim deductible.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/employer/forms/deductible/default.asp\">Completeonline</a> <br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/U-148.pdf\">ViewPDF</a> "],["U-149","Sponsor Certification Application","Organizations should use this form if they are interested in becoming a sponsor for BWC's group-retrospective rating plan, group-experience rating plan or both.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/U-149.pdf\">ViewPDF</a> "],["U-157","Request to Exclude Work-Based Learning Pilot Program Claims from Employer's Experience","Employers participating in this pilot program can use this form to ensure that claims arising from the program do not negatively impact their workers' compensation premiums.","Employers","Programs","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-157.pdf\">ViewPDF</a> "],["U-158","Pre-audit Questionnaire and Employer's Authorization","Employers can use this form to prepare for a BWC audit, providing necessary information and granting access to relevant records.","Employers","Reporting","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/U-158.pdf\">ViewPDF</a> "],["U-159","Other States Coverage - Trucking Supplemental Application","Trucking companies can use this form to ensure their drivers and other employees are covered under Ohio's workers' compensation system when working in other states.","Employers","Coverage","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-159.pdf\">ViewPDF</a> "],["U-160","Fall Protection in Construction Supplemental Questions","Construction employers can use this form to detail their fall protection programs, demonstrating compliance with safety regulations and reducing the risk of fall-related injuries.","Employers","Safety","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-160.pdf\">ViewPDF</a> "],["U-20","Application for Individual-Retrospective Rating Plan for Private Employers","Private employers can use this form to apply for the retrospective rating plan, an alternative rating plan that allows them to initially pay BWC less payroll premium.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/employer/forms/retrorating/default.asp\">Completeonline</a> <br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/U-20.pdf\">ViewPDF</a> "],["U-21","Application for Individual-Retrospective Rating Plan for Public Employers","Public employers can use this form to apply for the retrospective rating plan, an alternative rating plan that allows them to initially pay BWC less payroll premium.","Employers","Programs","<a href=\"https://www.bwc.ohio.gov/employer/forms/retrorating/default.asp\">Completeonline</a> <br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/U-21.pdf\">ViewPDF</a> "],["U-3","Application for Ohio Workers' Compensation Coverage","Employers can apply for Ohio workers' compensation coverage with this form if they have one or more employees.","Employers","Coverage","<a href=\"/forms-and-publications/application-for-ohio-workers-compensation-coverage-u-3\">Completeonline</a><br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-3.pdf\">ViewPDF</a> "],["U-3E","Application for Exemption from Ohio Workers' Coverage and Waiver of Benefits","Employers can use this form to apply for religious exemption from paying BWC premiums or assessments, or for self-insuring employers paying compensation and benefits directly to their employees who completed the form.","Employers","Coverage","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-3E.pdf\">ViewPDF</a> "],["U-3S","Application for or Request to Cancel Elective Coverage","Simplify workers' comp adjustments using this form. You can add or cancel coverage for sole proprietors, partners, LLC officers & more. ","Employers","Coverage","<a href=\"/forms-and-publications/application-for-or-request-to-cancel-elective-coverage-u-3s\">Completeonline</a><br><a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-3S.pdf\">ViewPDF</a> "],["U-59","Request for Retroactive Coverage and Penalty Abatement or Waiver of Payroll True-Up Penalties","Employers or their representatives can use this form to request retroactive coverage and penalty abatement for a lapse in coverage or a waiver of payroll true-up penalties.","Employers","Waivers","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/forms/U-59.pdf\">ViewPDF</a> "],["U-69","Contract for Coverage of State Agency or Political Subdivision","Public employers can use this form to obtain optional workers' compensation coverage for individuals not considered employees.","Employers","Coverage","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-69.pdf\">ViewPDF</a> "],["U-80","Apprenticeship Elective Coverage Contract","Apprenticeship organizations can use this form to elect workers' compensation coverage for its apprentices as if they are the employer. ","Employers","Coverage","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/U-80.pdf\">ViewPDF</a> "],["UA-3","Professional Employer Organization Client Relationship Notification","PEOs can use this form to notify BWC of a new client, change of relationship with a current client or termination of a client. ","Employers","Administration","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/UA-3.pdf\">ViewPDF</a> "],["UA-3 SI","Self-Insured Professional Employer Organization (PEO) Client Relationship Notification","Use this form to notify BWC of a new client or a termination of a client. ","Employers","Administration","<a href=\"https://dam.assets.ohio.gov/image/upload/info.bwc.ohio.gov/Employers/UA-3SI.pdf\">ViewPDF</a> "],["W-9","Request for Taxpayer Identification Number and Certification","Use this form to provide your correct TIN to the person who is required to file an information return with the IRS.","Workers \r\n<br>\r\nEmployers\r\n<br>\r\nProviders","IRS","<a href=\"https://www.irs.gov/pub/irs-pdf/fw9.pdff\">ViewPDF</a> "],["WAGES-EMP","Employer Report of Employee Earnings","Injured workers can use the this form to submit wage info which will help establish rates used for paying various types of compensation.","Employers","Wages","<a href=\"/forms-and-publications/employer-report-of-employee-earnings-wages-emp\">Completeonline</a> <br><a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/Wages-Emp.pdf\">ViewPDF</a> "],["WAGES-IW","Injured Worker Earnings Statement","Injured workers can use this form to document their earnings, which is necessary for calculating compensation benefits for wage loss under the workers' compensation system.","Workers","Wages","<a href=\"https://www.bwc.ohio.gov/downloads/blankpdf/Wages-IW.pdf\">ViewPDF</a> "],[""]],"errors":[],"meta":{"delimiter":",","linebreak":"\r\n","aborted":false,"truncated":false,"cursor":68134}}