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Blank Ohio C 240 PDF Form

The Ohio C 240 form is a Settlement Agreement and Application for Approval of Settlement Agreement specifically designed for state-fund workers' compensation claims. This form facilitates the settlement process between injured workers and their employers, ensuring that all unresolved issues are suspended while ongoing compensation and medical payments continue until the settlement is finalized. To begin the settlement process, please fill out the form by clicking the button below.

Article Guide

The Ohio C 240 form serves as a vital tool in the settlement process for workers' compensation claims, specifically for those involving state-fund employers. This form, officially titled the Settlement Agreement and Application for Approval of Settlement Agreement, is essential for injured workers seeking to resolve their claims. It requires signatures from both the injured worker and the employer, except in cases where the employer is no longer operational in Ohio. By submitting this application, both parties agree to suspend any unresolved issues, although ongoing compensation and medical payments will continue until the settlement is officially approved by the Bureau of Workers' Compensation (BWC). The form also outlines the responsibilities regarding medical expenses, particularly noting that the injured worker will be liable for costs incurred after the effective settlement date. Additionally, it includes important provisions for Medicare beneficiaries, emphasizing that Medicare will not cover medical expenses related to the claim until certain conditions are met. Completing the Ohio C 240 form accurately is crucial, as it not only facilitates the settlement process but also ensures compliance with Ohio Revised Code 4123.65, protecting the rights of both the injured worker and the employer.

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Settlement Agreement and Application for

Approval of Settlement Agreement

(For state-fund claims only) (Self-insured claims ﬁle SI-42)

File this application to settle workers' compensation claims with state-fund employers. Ohio Revised Code 4123.65 requires the injured worker and the employer to sign settlement applications unless the employer is no longer doing business in Ohio. If the claim to be settled is a state-fund claim, and the employer is now self-insuring, BWC charges the self-insuring employer dollar for dollar for any portion of the settlement attributed to past, present or future Disabled Workers' Relief Fund (DWRF) liability.

By iling this application, the injured worker and the employer agree all unresolved issues will be suspended. All ongoing compensation and medical payments, however, will continue until the effective settlement date. The effective settlement date is the mailing date of BWC's approval of settlement agreement.

Please Note: The persons involved with iling this settlement agree if any other claim(s) or part of any claim(s) being settled has been recognized or allowed, then the cost of all medical services, hospital bills, drugs and medicines with date(s) of service or illing of related prescriptions (not to exceed a 30-day supply) provided to the injured worker before the effective settlement date, shall be the responsibility of the state insurance fund, provided such costs result from the allowed conditions of the claims and are properly payable under current medical payment guidelines. The costs of all medical services, hospital bills, drugs and medicine with the date(s) of service of illing of related prescriptions (not to exceed a 30-day supply) provided to the injured worker on or after the effective settlement date are the responsibility of the injured worker.

By initialing this box, the injured worker acknowledges he or she has read and understands the above statement.

Special Notice to Medicare Beneﬁciaries

Medicare does not pay medical bills for conditions covered by your workers' compensation claim. If a settlement of your workers' compensation claim is reached, and the settlement allocates certain amounts for future medical expenses, Medicare does not pay for those services until medical expenses related to your workers' compensation claim equal the amount of the lump sum settlement allocated to future medical expenses. For additional information, please call the Medicare coordination of beneits contractor at (800) 999-1118.

Instructions

•For lost-time and medical-only claims, mail this completed application to your nearest customer service ofice.

•Call 1-800-OHIOBWC for the address of your local customer service ofice.

•To settle a claim with a self-insuring employer, please complete and forward form SI-42, or contact your self-insuring employer for other forms setting out the agreement between the injured worker and self-insuring employer.

•To facilitate settlement of this claim, please forward any unpaid bills to your managed care organization.

•Include a list of any unpaid bills you are aware of or attach copies of any unpaid bills or statements.

Application for Approval of Settlement Agreement

The injured worker and employer, as agreed to below, make application to BWC for approval of a inal settlement in the injured worker's claim(s).

Parties to the Claim

Injured worker name	Social Security number			Date of birth		Phone number
						(	)

Address	City				State	ZIP code

Injured worker representative name			ID number			Phone number
						(	)
Address	City				State	ZIP code

Employer name	Risk number			Fax number		Phone number
				(	)	(	)
Address	City				State	ZIP code

Employer representative name				Fax number		Phone number
				(	)	(	)
Address	City				State	ZIP code

Information on other relevant employers is attached	Yes	No

Claim(s) to be Included In Settlement

Claim Number*

Requested amount for

Proposed allocation of requested settlement amount

complete settlement**

Indemnity

Prescription drugs

Medical

*List any claims speciically excluded from settlement:

**Please explain any request for a partial settlement:

Clearly set forth the circumstances by reason of which the proposed settlement is deemed desirable.

Has information on other relevant claims been attached?

Are you receiving, or have you applied for Medicare beneﬁts?

Yes

Are you receiving medical treatment at this

Who is your treating physician(s)?

Wages at time of injury?

time?

Yes

Are you currently working?

If yes, who is your present employer?

What is your present occupation?

What are your present wages?

Yes

BWC-1372 (Rev. 2/1/2007)

C-240

Employer Signature

(Required by ORC 4123.65 unless the employer is no longer doing business in Ohio)

Instructions

•Please check one of the following boxes and sign below. Your signature does not waive the employer's right to withdraw consent to the settlement by providing written notice to the employee and the BWC administrator within 30 days after the administrator issues the approval of the settlement agreement.

A. The employer is supportive of and agreeable to a settlement up to the amount listed on the front of this application.

B. The employer does not agree with the requested settlement terms but will participate with the BWC in the negotiation process.

C. The employer is supportive of and agreeable to settlement of the claims listed on the front of this application. However, the employer will not participate in the settlement negotiations and requests the BWC to negotiate the settlement on behalf of the employer.

D. The employer is not agreeable to settlement of the claim(s) listed on the front of this application.

By signing this agreement, an employer that is currently self-insured acknowledges its obligation to reimburse BWC for the portion of the settlement amount allocated to DWRF costs of the above-referenced claim(s). BWC will bill the DWRF portion of the settlement to the self-insuring employer, even if the injured worker has not yet been determined to be permanently and totally disabled or currently eligible for DWRF beneﬁts.

Employer signature

Telephone number

()

Title	Date

Fax number

()

Settlement Agreement and Release

As set forth in this agreement, the injured worker for and in consideration of the receipt of the settlement amount approved by the BWC, which sum will be paid from the appropriate fund on behalf of the employer after approval by the BWC administrator, unless within 30 days after such approval the administrator, the employer or the injured worker, withdraws consent to, or unless the Industrial Commission of Ohio (IC) disapproves the agreement, does hereby for him/herself and for anyone claiming by, through or under him/her, forever release and discharge the above referenced employer, its oficers, employees, agents, representatives, successors and assigns, the IC, the BWC, the appropriate fund, and all persons, irms or corporations from any or all claims, demands, actions or causes of action incurred on or prior to the date of the approval of this agreement, arising out of Ohio Revised Code Chapter 4121. or 4123., which he/she now has or which he/she hereafter claim to have, whether known or unknown by reason of or in any manner growing out of the claims or parts thereof set forth above. The injured worker further understands and agrees that any amount paid pursuant to this agreement is subject to any valid court-ordered child support. The persons involved with iling this settlement agree that if any claim(s) or part of any claim(s) being settled has been recognized or allowed, then the cost of all medical services, hospital bills, drugs and medicines with date(s) of service or illing of related prescriptions (not to exceed a 30-day supply) provided to the injured worker before the effective settlement date, shall be the responsibility of the state insurance fund, provided such costs result from the allowed conditions of the claims and are properly payable under current medical payment guidelines. The costs of medical services hospital bills, drugs and medicines (not to exceed a 30-day supply) provided to the injured worker on or after the effective date of the settlement date are the responsibility of the injured worker.

By initialing this box, the injured worker acknowledges he or she has read and understands the above statement.

Also as set forth above, the injured worker understands that any settlement amounts allocated for future medical services must be used for medical services before Medicare will consider payment for services for the conditions of the workers' compensation claim.

Settlement of any claim(s) included in this agreement in no way impairs BWC's statutory rights to subrogation recovery. Also, be advised that upon a inding of fraud, the administrator retains the right to rescind this settlement agreement and re-open the claim for an administrative overpayment hearing and referral for criminal prosecution.

Injured worker signature

Date

Power of Attorney

By signing below the injured worker grants a limited power of attorney to the attorney of record for the purpose of receiving the warrant issued because of this settlement agreement.

Injured worker signature

Date

Representative signature

Date

BWC-1372 (Rev. 2/1/2007)

C-240

➤ PDF File

Form Specifications

Fact Name	Description
Purpose	The Ohio C 240 form is used to apply for the approval of a settlement agreement in workers' compensation claims for state-fund employers.
Governing Law	This form is governed by Ohio Revised Code 4123.65, which outlines the requirements for settlement applications.
Signatures Required	Both the injured worker and the employer must sign the application unless the employer is no longer in business in Ohio.
Ongoing Payments	All ongoing compensation and medical payments will continue until the settlement date, which is the date BWC approves the settlement.
DWRF Liability	If the employer becomes self-insured, they are responsible for any settlement amounts related to the Disabled Workers' Relief Fund (DWRF).
Medicare Notice	Medicare does not cover medical expenses for conditions related to a workers' compensation claim until the settlement amount for future medical expenses is exhausted.
Application Submission	The completed application should be mailed to the nearest customer service office of the BWC.
Unpaid Bills	Injured workers should forward any unpaid bills to their managed care organization to facilitate the settlement process.
Power of Attorney	The injured worker can grant a limited power of attorney to their attorney for receiving the settlement warrant.

Ohio C 240: Usage Guidelines

Filling out the Ohio C 240 form is an important step in settling a workers' compensation claim with a state-fund employer. This form requires detailed information about both the injured worker and the employer, as well as specifics about the claim being settled. Completing it accurately ensures that the settlement process can move forward smoothly.

Gather necessary information: Collect all required details about the injured worker, employer, and the claim. This includes Social Security numbers, addresses, and contact information.
Complete the parties' information: Fill in the injured worker's name, Social Security number, date of birth, phone number, and address. Repeat this for the employer and their representative.
Claim details: List the claim number, the requested settlement amount, and how you propose to allocate that amount among indemnity, prescription drugs, and medical expenses.
Attach relevant documents: Indicate if you have attached information about other relevant employers and claims. Make sure to include any unpaid bills or statements.
Answer additional questions: Respond to questions regarding Medicare benefits, current medical treatment, and employment status. Provide details about the treating physician and current wages.
Employer's agreement: The employer must check one of the provided boxes regarding their stance on the settlement and sign the form.
Injured worker's signature: The injured worker must sign the agreement to confirm understanding of the settlement terms.
Power of attorney (if applicable): If an attorney is involved, the injured worker should sign to grant limited power of attorney for receiving the settlement warrant.
Review the form: Before mailing, double-check all entries for accuracy and completeness.
Submit the form: Mail the completed application to the nearest customer service office or the appropriate self-insured employer, as applicable.

Your Questions, Answered

What is the Ohio C 240 form?

The Ohio C 240 form is an application used to settle workers' compensation claims for state-fund employers in Ohio. It serves as a Settlement Agreement and Application for Approval of Settlement Agreement. This form must be completed and submitted by both the injured worker and the employer to finalize the settlement of a claim. It is crucial for ensuring that all parties involved agree to the terms of the settlement.

Who needs to sign the Ohio C 240 form?

Both the injured worker and the employer are required to sign the Ohio C 240 form, as stipulated by Ohio Revised Code 4123.65. However, if the employer is no longer in business in Ohio, their signature is not necessary. This ensures that all parties are in agreement regarding the settlement terms before it is submitted for approval.

What happens to ongoing compensation and medical payments after filing the form?

Once the Ohio C 240 form is filed, all unresolved issues related to the claim will be suspended. However, ongoing compensation and medical payments will continue until the effective settlement date, which is the date BWC approves the settlement agreement. This means that the injured worker will still receive necessary support until the settlement is finalized.

What are the responsibilities regarding medical costs after the settlement?

After the effective settlement date, the injured worker is responsible for all medical services, hospital bills, drugs, and medicines incurred. These costs are applicable to services provided on or after the effective date of the settlement. However, any medical expenses incurred prior to that date will be covered by the state insurance fund, provided they relate to the allowed conditions of the claims.

What should Medicare beneficiaries know about the settlement?

Medicare beneficiaries must be aware that Medicare does not cover medical expenses for conditions related to a workers' compensation claim. If a settlement allocates funds for future medical expenses, Medicare will not pay for those services until the total medical expenses related to the claim equal the amount allocated in the settlement. For further assistance, beneficiaries can contact the Medicare coordination of benefits contractor.

How should the completed Ohio C 240 form be submitted?

The completed Ohio C 240 form should be mailed to the nearest customer service office of the Bureau of Workers' Compensation (BWC). For guidance on where to send the form, individuals can call 1-800-OHIOBWC. If the claim involves a self-insuring employer, the appropriate forms should be obtained from them, and any unpaid bills should be forwarded to the managed care organization to facilitate the settlement process.

Common mistakes

Failing to read the entire form carefully. Many individuals rush through the application, missing crucial details that could affect their settlement.
Not providing accurate personal information. Errors in the injured worker's name, Social Security number, or date of birth can lead to delays or rejections.
Neglecting to include all relevant claims. Omitting any claim numbers or details can complicate the settlement process.
Forgetting to sign the form. Both the injured worker and the employer must sign the application; otherwise, it is considered incomplete.
Overlooking the requirement for employer consent. If the employer is still in business, their signature is necessary for the settlement to proceed.
Not initialing the acknowledgment box. This step confirms that the injured worker understands their responsibilities regarding medical costs post-settlement.
Ignoring the instructions for submitting the application. Each claim type has specific mailing addresses, and sending it to the wrong location can cause delays.
Failing to attach supporting documents. Unpaid bills or statements related to the claim should be included to facilitate the settlement process.
Not consulting with a legal representative. Some individuals attempt to navigate the process without professional guidance, which can lead to mistakes.
Neglecting to check Medicare eligibility. If the injured worker is a Medicare beneficiary, they must understand how the settlement affects their benefits.

Documents used along the form

The Ohio C 240 form is crucial for settling workers' compensation claims, particularly for state-fund claims. Alongside this form, several other documents may be necessary to ensure a smooth settlement process. Below are four commonly used forms and documents that often accompany the Ohio C 240 form.

Settlement Agreement and Release: This document outlines the terms of the settlement between the injured worker and the employer. It releases the employer from future claims related to the injury, provided the settlement is approved by the Bureau of Workers' Compensation (BWC).
Application for Approval of Settlement Agreement: This application is submitted to the BWC for the final approval of the settlement. It requires signatures from both the injured worker and the employer and details the claims being settled.
Form SI-42: This form is specifically for settling claims with self-insured employers. It details the agreement between the injured worker and the self-insured employer, ensuring that all parties are aware of their responsibilities regarding the settlement.
Medical Bills and Statements: Any unpaid medical bills related to the claim should be submitted to the managed care organization. This documentation helps clarify the financial responsibilities before and after the settlement date.

Using these documents in conjunction with the Ohio C 240 form can streamline the settlement process and help avoid potential complications. It’s essential to ensure all necessary paperwork is complete and accurate for a successful resolution of your claim.

Similar forms

Application for Approval of Settlement Agreement: This document is similar to the Ohio C 240 form as it also requires signatures from both the injured worker and employer. It serves to request approval for a final settlement of workers' compensation claims, ensuring that all parties are in agreement regarding the terms of the settlement.
Settlement Agreement and Release: Like the Ohio C 240, this document formalizes the settlement process. It releases the employer from any further claims related to the injury after the settlement is approved, ensuring that the injured worker acknowledges the closure of the claim.
Self-Insured Employer Settlement Agreement (SI-42): This document is used specifically for settling claims with self-insured employers. It parallels the Ohio C 240 form by outlining the responsibilities of both the injured worker and the employer in the settlement process, particularly regarding the allocation of costs.
Medicare Set-Aside Agreement: This document is relevant for injured workers who are Medicare beneficiaries. It is similar to the Ohio C 240 form in that it addresses future medical expenses related to the workers' compensation claim, ensuring that Medicare does not pay for services that should be covered by the settlement.

Dos and Don'ts

When filling out the Ohio C 240 form, it's important to approach the process carefully. Here’s a list of what you should and shouldn't do to ensure a smooth application experience.

Do read the entire form thoroughly before starting.
Do gather all necessary documentation, including any unpaid bills.
Do ensure both the injured worker and employer sign the application.
Do provide accurate information regarding all claims included in the settlement.
Don't leave any sections of the form blank; fill out every required field.
Don't submit the application without checking for errors or missing information.
Don't forget to include your treating physician's information if applicable.
Don't ignore any specific instructions regarding submission or additional documentation.

Misconceptions

Understanding the Ohio C 240 form can be challenging, and several misconceptions often arise. Here are eight common misunderstandings regarding this important document:

Misconception 1: The Ohio C 240 form is only for self-insured claims.

This form is primarily designed for state-fund claims but can also apply to self-insured claims when certain conditions are met. It is essential to check the specifics of your situation.

Misconception 2: Signing the C 240 form means giving up all rights to future claims.

Signing this form does not automatically forfeit the right to future claims. It only pertains to the claims specified in the settlement agreement.

Misconception 3: The employer's signature on the C 240 form is optional.

The employer's signature is required unless the employer is no longer doing business in Ohio. This ensures that both parties agree to the terms of the settlement.

Misconception 4: All medical expenses will be covered after signing the C 240 form.

While some medical expenses may be covered, the injured worker is responsible for any medical services received after the effective settlement date. Understanding these responsibilities is crucial.

Misconception 5: The effective settlement date is the same as the date of signing the form.

The effective settlement date is actually the mailing date of the Bureau of Workers' Compensation's approval of the settlement agreement, not the date when the form is signed.

Misconception 6: Medicare will cover all medical expenses related to the claim after the settlement.

Medicare does not pay for medical bills associated with conditions covered by the workers' compensation claim until the expenses equal the settlement amount allocated for future medical expenses.

Misconception 7: Once the C 240 form is filed, the settlement is final and cannot be changed.

The settlement can be rescinded within 30 days of approval if any party withdraws consent. This allows for some flexibility in the process.

Misconception 8: The C 240 form is a simple document that requires little attention to detail.

In reality, the C 240 form contains many important details that require careful consideration. Misunderstandings can lead to significant consequences, so it is advisable to review it thoroughly.

Key takeaways

When filling out and using the Ohio C 240 form, several key points should be kept in mind:

The Ohio C 240 form is used to settle workers' compensation claims with state-fund employers.
Both the injured worker and the employer must sign the settlement application, unless the employer is no longer in business in Ohio.
If the employer is self-insured, they will be charged for any portion of the settlement related to the Disabled Workers' Relief Fund (DWRF).
Filing the application suspends all unresolved issues, but ongoing compensation and medical payments will continue until the settlement is approved.
The effective settlement date is the date BWC mails the approval of the settlement agreement.
Medical costs incurred before the effective settlement date are the responsibility of the state insurance fund, provided they are related to allowed conditions.
After the effective settlement date, the injured worker is responsible for all medical costs.
Medicare will not pay for medical bills related to the workers' compensation claim until the settlement amount allocated for future medical expenses is exhausted.
For lost-time and medical-only claims, the completed application should be mailed to the nearest customer service office.
It is essential to provide any unpaid bills to the managed care organization to facilitate the settlement process.