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Date Customer ID number Contact name Telephone number
Company name Email address
Address City State ZIP code
BWC-5026 (Rev. 12/03/2013)
OS-24
Quantity Form no. Title
AC-3 Temporary Authorization
C-5 Additional Information for Death Benefits
C-9 Physician’s Report/Treatment Plan for Industrial
Injury or Occupational Disease
C-9A Request for Additional Medical Documentation for C-9
C-11 Request to Appeal MCO Medical Treatment/
Service Decision
C-17 Pharmacy Invoice
C-18 Wage Agreement
C-19 Service Invoice
C-23 Change of Doctor Request
C-32 Application for Lump Sum Advancement
C-44 Physician’s Certificate in Proof of Death
C-58
Application for Adjustment of Claim in Case of Fatal
Injury
C-59 Self-Insurer’s Agreement as to Compensation on
Account of Death
C-60
Injured Worker Statement for Reimbursement of Travel
Expense
C-77 Injured Workers’ Change of Address
C-84 Request for Temporary Total Compensation
C-86 Motion
C-92
Application for Determination of the Percentage of
Permanent Partial Disability or Increase of Permanent
Partial Disability
C-94A Wage Statement
C-101 Authorization to Release Medical Information
C-108 Request for Waiver of Appeal
C-110 Agreement to Select The State of Ohio as the
State of Exclusive Remedy
C-112 Agreement to Select a State Other than Ohio as
the State of Exclusive Remedy
C-140 Application for Wage Loss Compensation
C-141 Wage Loss Statement for Job Search
C-143 DEP Physician’s Report of Work Ability
C-159 Waiver of Workers’ Compensation Benefits for
Recreational or Fitness Activities
Quantity Form no. Title
C-190 Justification of Medical Necessity for Seating/
Wheeled Mobility
C-230 Authorization to Receive Workers’ Compensation
Check
C-240A Notice of Exception to Employer’s
Signature Requirement
C-240 Notice of Exception to Employer’s
Signature Requirement
C-241 Amended Settlement Agreement and Release
CHP-4A Application for Handicapped Reimbursement
FROI-1 F
irst Report of Injury, Occupational Disease or Death
MEDCO-13
Application for Provider Enrollment and Certification
MEDCO-13A
Application for Provider Enrollment-Non Certification
MEDCO-14 Report of Work Ability
R-1 Authorization of Representative of Employer
R-2 Authorization of Representative of Injured Worker
RH-1 Rehabilitation Agreement
RH-2 Individualized Vocational Rehabilitation Plan
RH-5 Trainer’s Report
RH-6 On-The-Job Training Agreement
RH-7 Loan/Lease Agreement for Tools and Equipment
RH-10 Injured Worker’s Record of Job Search Contacts
RH-18
Authorization for Living Maintenance Wage Loss (LMWL
RH-19 Employer Incentive Contract
RH-21 Vocational Rehabilitation Closure Report
RH-24 Gradual Return to Work Contract Employer
Reimbursement Method
SI-28
Filing of an Allegation Against a Self-Insured Employer
SI-42
Self-Insured Joint Settlement Agreement and Release
SI-43 Acknowledgment of the Self-Insured Joint
Settlement Agreement and Release
U-3
Application for Ohio Workers’ Compensation Coverage
U-3S Application for Optional Supplemental Coverage
U-117 Application for Optional Supplemental Coverage
U-118 Notification of Business
Acquisition/Merger or Purchase/Sale
Forms available
Office Services Forms & Publications
3655 Brookham Drive
Grove City, Ohio 43123
Call: 1-800-OHIOBWC, and listen to the options
Fax: 614-621-5746