(A) Preparation and execution of forms.
(1) Applications for the payment of compensation and medical expenses from the state
insurance fund by reason of injury (form C-1, private fund; form C-71, public fund),
and by reason of occupational disease (form OD-4, private and public fund) shall be
completed, in the parts designated on the forms, by both the employee and the employer.
The employee and the employer shall sign the applications at the points designated.
(2) Applications for payment, from the state insurance fund, of medical expenses
only in injury claims (form C-3, private fund; form C-72, public fund), and in occupational
disease claims (form OD-3, public and private fund), shall be completed and signed by
the employer and the employee.
(3) Applications for death benefits from the state insurance fund where the
death is a result of the injury (form C-2, public and private fund), and where
the death is the result of an occupational disease (form OD-2, public and private
fund) shall be completed and signed by the applicant or applicants in the parts
designated on the forms. The employer shall also complete and sign the designated
part on such forms.
(4) Applications for compensation and/or benefits by employees of self-insuring
employers (form C-50 in injury claims; form OD-1-22 in occupational disease claims)
shall be completed and signed by the employee and the employer in the parts designated
on the forms. In situations where there is no prescribed form, a notice in writing
shall be given in a manner sufficient to inform that a claim for benefits is being
(5) Applications for compensation and/or benefits by employees of noncomplying employers
(form C-67 in injury claims and occupational disease claims; form C-69 in death claims)
shall be completed by the employee, or the person or persons claiming death benefits and
shall be signed and verified, under oath.
(6) An injured or disabled employee who is a minor (under eighteen years of age) shall
file his claim in his own name and right. A claim signed by such minor employee shall be
sufficient to initiate proceedings for compensation and/or benefits.
(7) In the event the injured or disabled employee is unable to complete an application
for benefits by reason of physical or mental disability, the application may be completed
and filed by such employee's spouse, next friend, by the guardian of employee or by the
employee's employer. In claims for death benefits where the dependents are a spouse and
one or more minor children, it shall be sufficient for the spouse to make application for
benefits on behalf of the spouse and the minor children. In the event a dependent minor
child has a guardian of the person other than the spouse of the deceased, such guardian
shall execute the application on behalf of such minor child. If there is no spouse
surviving, the application on behalf of the dependent minor children, or children who
are mentally or physically incapacitated, may be filed by a guardian or next friend
of such children.
(8) It shall be the duty of every employer to assist injured or disabled employees in
the preparation and submission of applications for compensation and/or benefits. In
the event that the employer refuses, neglects or unduly delays the completion of an
application, such application may be filed without the part pertaining to the employer
having been completed. The fact of refusal or neglect should be noted upon the
application or with it by way of separate letter.
(9) In cases where the death of the employee is not the result of injury or occupational
disease, the application for compensation may be made as provided in sections 4123.57
and 4123.60 of the Revised Code on application form C-6.
(10) Application for payment of the balance of percentage permanent partial
disability compensation, awarded under division (A) of section 4123.57 of the Revised
Code prior to the employee's death, shall be made by his dependents by way of a motion,
in writing, completed and signed by the applicant or applicants. Such motion may be
filed whether death was related or unrelated to an industrial injury or occupational
(B) Certification by the employer on applications for benefits.
(1) Employers shall accept or deny the validity of every claim filed against
their risks within the time as required by the rules of the industrial commission.
If the employer fails to comply with the established time limits, the bureau shall
take such further action in the claim as provided for by the rules of the
(2) If the employer accepts the validity of the claim, he will sign the application
form at the designated point.
(3) If the employer denies the validity of the claim, the employer shall sign the
application form at the point indicated and cross out the printed text of certification
and waiver of hearing. In the space provided on the form or on a separate sheet of paper
to be attached to the form, the employer shall state the reasons for denying the validity
of the claim.
(4) Certification by the employer in state fund cases shall not be determinative of
compensability. Every such claim is subject to administrative review as to
(5) An employer's certification of a claim may be made by the employer, by an officer
of the business entity which is the employer, or by a duly designated representative
of the employer. The person certifying a claim for the employer shall indicate in what
capacity he is employed (title). No other person or entity may make such certification.
No person may certify his own claim, except in cases of a sole proprietor who has
obtained coverage for himself as an employee within Chapter 4123. of the Revised Code.
(C) Place and manner of filing applications for benefits.
Any application in writing for compensation and/or benefits shall be
accepted for filing in any office of the bureau or commission during working hours,
and applications may be filed by mail.
(D) Time limitations within which claims must be filed.
(1) Injury claims applying for compensation and/or benefits shall be in writing
and shall include the specific part or parts of the body alleged to have been
injured. Such claims shall be forever barred unless a written notice of the
specific part or parts of the body claimed to have been injured is filed with the
bureau of workers' compensation or the industrial commission within two years from
the date when injured, unless the applicable statute of limitations is extended
due to the employer's failure to file a report as required by section 4123.28 of
the Revised Code. Any claim or application for compensation and/or benefits for an
injury to any part or parts of the body not specified in the original claim will
be barred unless written notice of the additional part or parts of the body claimed
to have been injured is filed by the claimant with the bureau of workers' compensation
or the industrial commission within two years of the date when injured.
(2) In self-insuring employers' claims, the two-year time limitation is tolled if
compensation or benefits have been paid by the self-insuring employer within the
period. "Benefits" means payment by the self-insuring employer to, or on behalf of,
an employee for:
(a) A hospital bill;
(b) A medical bill for treatment by a licensed physician, other than a
salaried physician in the employ of the self-insuring employer;
(c) An orthopedic or prosthetic device.
(3) The bureau of workers' compensation and the industrial commission have
continuing jurisdiction over a claim which meets the requirement of section
4123.84 of the Revised Code, including jurisdiction to award compensation
and/or benefits for a condition (or conditions) or disability developing in part
or parts of the body not specified pursuant to division (A)(1) of section 4123.84
of the Revised Code, if it is found that the condition (or conditions) or disability
was due to and a result of or a residual of the injury to one of the parts of the
body set forth in the written notice filed pursuant to division (A)(1) of section
4123.84 of the Revised Code.
(4) Claims for occupational disease must be filed within two years after the
disability begins, or within such longer period as does not exceed six months
after diagnosis by a licensed physician, as provided in section 4123.85 of the
Revised Code, excepting claims enumerated in paragraph (D)(5) of this rule, other
than berylliosis, or where the applicable statute of limitations is extended due
to the employer's failure to file a report as required by section 4123.28 of the
(5) Special statutory provisions (section 4123.68 of the Revised Code) exist as
to claims for silicosis, cardiovascular and pulmonary diseases of fire fighters
and police officers, coal miners' pneumoconiosis, asbestosis, berylliosis,
radiation illness and all other occupational disease of the respiratory tract
resulting from injurious exposures to dust:
(a) Compensation is payable in silicosis, coal miners' pneumoconiosis,
cardiovascular and pulmonary disease of fire fighters and police officers and in
all other dust caused diseases of respiratory tract, except berylliosis, only for
temporary total or permanent total disability or death and only if such disability
and/or death occurs within eight years after the last injurious exposure.
(b) If disability or death is from injurious exposure occurring after January 1,
1976, the eight-year limitation shall not apply.
(c) There must be injurious exposure in this state for a period amounting in all
to at least three years. In cases of cardiovascular and pulmonary disease of fire
fighters and/or police officers, some of this must be after January 1, 1967. In
cases of silicosis, asbestosis and coal miners' pneumoconiosis, part of the
injurious exposure must be after October 12, 1945.
(d) In the event of death following continuous total disability commencing within
eight years after the last injurious exposure, the requirement of death within
eight years does not apply.
(e) The above provisions govern asbestosis claims except that the eight-year
limitation does not apply.
(f) The above provisions govern berylliosis and radiation claims except that
payment of compensation is not restricted to temporary total, permanent total
disability and/or death, and the minimum three-year injurious exposure in the
state is not required. In radiation claims, where disability began prior to
November 2, 1959, the general occupational disease provisions apply.
(g) The above claims, except claims for berylliosis, must be filed within one year
after total disability begins or within such longer period as does not exceed six
months after diagnosis by a licensed physician. Claims for berylliosis must be
filed within the time as provided in paragraph (D)(4) of this rule. If the
disability due to the disease began on or after January 1, 1979, or was diagnosed
by a licensed physician on or after January 1, 1979, such claims shall be forever
barred unless, within two years after the disability due to the disease began, or
within such longer period as does not exceed six months after diagnosis of the
occupational disease by a licensed physician, application is made to the industrial
commission, the bureau, or to the employer in the event such employer has elected
to pay compensation or benefits directly, or the applicable statute of limitations
is extended due to the employer's failure to file a report as required by section
4123.38 of the Revised Code.
(6) Death claims, alleging that death is the result of injury, must
be filed within two years of death or be forever barred, except as provided in
paragraphs (D)(8) and (D)(9) of this rule.
(7) Where the death is due to an occupational disease and death occurred on or
after November 2, 1959, the claim must be filed within two years of the death, as
provided in section 4123.85 of the Revised Code, except in claims included in
paragraph (D)(5) of this rule, which claims must be filed within six months after
the death. This exception does not apply to berylliosis death claims. Such claims
must be filed within two years after death or be forever barred.
(8) Civil defense claims for injury or death must be filed within one year from
the date when injured or from the date of death, or be forever barred. If an
injury claim has been filed within the one-year period and the claimant subsequently
dies, a death claim must be filed within six months after the death or be forever
(9) Public works relief employees' claims must be filed within two years after the
date when injured or the date of death, or be forever barred.
(10) Militia claims, special contract claims and apprentice claims are governed by
the general time limits applicable to injury and occupational disease claims, as
provided by sections 4123.84 and 4123.85 of the Revised Code.