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OhioBWC - Employer - Form:  (BWC Forms) - Employer Forms Descriptions

Employer forms descriptions

300AP - Summary of Work Related Injuries and Illnesses: Public employers are required to submit the master form to the Public Employment Risk Reduction Program by Feb. 1 for the previous calendar year. They are also required to post the form at each of their physical locations between Feb. 1 and April 30.

AC-2 - Permanent Authorization: The Authorized representative – Permanent authorization form allows an employer or employer representative to file the AC-2 on-line provided there is a hard copy of the AC-2 form on site at the employers. This authorization will supersede all permanent authorizations on file for the rep type chosen.

Extended Payment Plan: Employers experiencing financial difficulty use this form to request an extension on paying their premiums. If BWC approves the extension, we will notify the Attorney General's Office about the arrangement. Employers who receive the extension will maintain their workers' compensation coverage while they're making payments.

AC-3 - Temporary Authorization to Review Information (AC-3): Employers should use this form to allow third party administrators to review and work on certain workers' compensation matters on their behalf.

AC-3-ES - Temporary Authorization to Review Information (En Español): Employers should use this form to allow third party administrators to review and work on certain workers' compensation matters on their behalf.

BWC-7500 - Plan of Action: This form is completed by employers participating in any of the following BWC rating programs: Premium Discount Program +, Drug-Free Workplace Program (Level 2 and 3) and retrospective rating (tier 2). It is to be used by employers in recording actions they either plan to make or have taken to implement the requirements for each step of BWC's 10-Step Business Plan.

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. This form initiates the alternative dispute resolution (ADR) process.

C-18 - Wage Agreement: 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.

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.

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. BWC is not a party in this agreement. Regular (full) salary/wages includes any benefits that the employee would normally be entitled to if the employee was working. This form must be signed by the employee and the employer.

C-59 - Self-Insurers' 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. All parties must be in agreement before the self-insuring employer submits this form.

C-86 - Motion: Any party to the claim can use this form to request action on a claim from either BWC or the IC (i.e., allowance of additional condition(s) and/or benefit payments). This form should always be submitted with supporting documentation such as medical evidence.

C-86 - Motion (En Español): Any party to the claim can use this form to request action on a claim from either BWC or the IC (i.e., allowance of additional condition(s) and/or benefit payments). This form should always be submitted with supporting documentation such as medical evidence.

C-94-A - Wage Statement: This form is used to supply BWC or the self-insuring employer with the injured worker’s wage information. Wage information is needed to establish the rates used for paying various types of compensation. Wage information can include check stubs, payroll ledgers, W-2 or other federal earning reports. Employers or injured workers can complete this form. If the form is completed by an injured worker, it must be notarized.

C-101 - Authorization to Release Medical Information: Employers should make sure all their injured workers complete and sign this form to authorize the release of medical records relative to their work-related injury(s). Then, any medical providers who have rendered services relative to the injury can release information to BWC, the Industrial Commission, the employer, the managed care organization (MCO) or qualified health plan (QHP) and any authorized representatives. The form is intended to comply with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), although BWC is exempt from HIPAA requirements.

C-108 - WAIVER of Appeal Period: Injured workers, employers and/or their respective representatives should use this form to waive appeal rights on a BWC or IC order. Both parties must sign the waiver to waive (or cancel) the appeal period. A waiver signed by only one of the parties will not cause an appeal period to be cancelled.

C-110 - Employer/Employee Agreement to Select Ohio as the State of Exclusive Remedy for Workers’ Compensation Claims: Employers and their employees use this form to enter into a contract of employment outside of Ohio, when some or all of the work is to be performed outside of Ohio, and there is a possibility that the workers' compensation laws of both Ohio and another state could apply to the employment relationship. The C-110 designates Ohio as the state of exclusive remedy for the filing of a workers’ compensation claim and the employer must report the payroll to BWC. BWC must receive this form within 10 days of signature to be legally valid. Therefore, it is strongly encouraged to fax completed forms to 614-621-1435.

C-112 - Employer/Employee Agreement to Select a State Other Than Ohio as the State of Exclusive Remedy for Workers’ Compensation Claims: Employers and their employees use this form to enter into a contract of employment outside of Ohio, when some or all of the work is to be performed outside of Ohio, and there is a possibility that the workers compensation laws of both Ohio and another state could apply to the employment relationship. The C-112 designates a state other than Ohio as the state of exclusive remedy for the filing of a workers’ compensation claim and the employer does not have to report the payroll for the designated employee to BWC. Employers must have an active policy with BWC to file the C-112. They must include a certificate of insurance for the other state(s) or a policy declarations page. BWC must receive this form within 10 days of signature to be legally valid. Therefore, it is strongly encouraged to fax completed forms to 614-621-1435.

C-174 - Self-Insured Semiannual Report of Claim Payments: Self-insuring 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.

IC-167-T - Objection to Tentative Order Awarding Permanent Partial Disability: Injured workers, employers or their respective representatives should use this form to object to a tentative order awarding permanent partial disability compensation. The Industrial Commission (IC) or BWC must receive the form within 20 days of the date the tentative order was received. Once the objection is received, the IC will schedule a formal hearing. Objections can now also be submitted online through I.C.O.N., the IC's Web site.

C-240 - Settlement Agreement and Application for Approval of Settlement Agreement (for State Fund Claims Only): Injured workers should use this form to file for a claims settlement with BWC. To settle, the injured worker and employer must agree to the terms and both must sign the application. Settlements can cover one or more claims, medical payments only compensation only or both. Injured workers and employers can also agree to settle for all allowed conditions in the claims or just select conditions. Injured workers of self-insuring employers should use the self-insuring application, the SI-42.

CHP-4A - Application for Handicap Reimbursement: Employers use this form to request that a percentage of the costs in an employee's workers' compensation claim be charged to, or refunded from, the Statutory Surplus Fund. They must provide evidence that the injury, disease or death would not have happened if not for the employee's pre-existing handicap condition or the aggravation of a pre-existing handicap condition. The form includes a schedule of the qualifying handicap conditions.

DFSP-1 – 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. The purpose of this form is to help the employer identify root causes of the accident and implement corrective measures to prevent a similar accident from occurring in the future. The employer should complete and submit the accident report online within 30 days of the accident or 30 days of the employer becoming aware of the accident.

DFSP-3 (sample) 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. BWC requests participating employers complete this form online. This sample demonstrates how to complete the form.

DFSP-4 (sample) 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. BWC requests participating employers completed this form online. This sample demonstrates how to complete the form.

DFSP-5 – Safety Action Plan: Employers participating at the Advanced level of the Drug-Free Safety Program (DFSP) must complete and submit this Safety Action Plan within 60 days of the start of each program year. This form outlines the action steps the employer intends to implement during the remainder of the program year. The employer should design these action steps based on the results of the Safety Review (DFSP-2).

Reporting fraud
Employers can use this form to report workers' compensation fraud. With this form, they can provide an effective description of the subject’s suspected fraudulent activity. Note: To report workers’ compensation fraud, employers need only to suspect that fraud may have been committed.

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. The party completing the form should supply BWC with as much detailed information as possible. An electronic version of the FROI is available for filing online.

FROI-ES - First Report of an Injury, Occupational Disease or Death (En Español): Injured workers, employers or medical providers use this form to initiate a workers' compensation claim. The party completing the form should supply BWC with as much detailed information as possible. An electronic version of the FROI is available for filing online.

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 must attach current financial information (copy of the past three years, federal and state income tax returns) and have the form notarized.

MCO Selection Form
State-fund employers must select a managed care organization (MCO) or BWC may assign one to them. MCOs partner with employers to ensure claims are filed quickly, treatment for injured workers’ begins promptly and recovery programs are implemented to safely and quickly return injured employees to work.

MEDCO-6 - Waiver of Examination: BWC claims service specialists use this form to obtain agreement from employers to waive the legally mandated 90-day exam. Employers can waive the exam temporarily i.e., if the injured worker is hospitalized or scheduled for surgery or permanently, i.e., if the injury is catastrophic.

OCP-1 - Application for One Claim Program: Eligible, private, state-fund employers use this form to apply for the One Claim Program. The application period is from March 1 to the last business day in April for the program period beginning each July 1.

MEDCO-8 - Self-Insured Employer/Claimant 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.

OD-58-22 - Application for Adjustment of Claims in Case of Death on Account of Occupational Disease: Self-insuring employers submit this form when they cannot determine the correct rate(s) of benefits for the beneficiary or beneficiaries of an injured worker who has died as a result of a work-related injury. The Industrial Commission will determine benefit amounts.

R-1 - Authorization of Representative of Employer: Employers and their representatives use this form to notify BWC of the employer’s authorized representative.

R-4 - Application for Representative Identification Number:

RH-5 - Trainer’s Report: Employers 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 must submit these reports during the on the job training program as directed by the vocational case manager.

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. This form is an agreement between the employer, injured worker and case manager to provide the injured worker with an opportunity to obtain and upgrade vocational skills through actual work experience, and permanent employment after successful completion of the training.
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. This form is an agreement between the employer, injured worker and vocational case manager to help the injured worker return to work while compensating the employer for initial losses in productivity and hours worked. Employer incentive contracts are offered for injured workers who have either successfully completed an initial vocational rehab plan or are participating in an established transitional work program at the employer’s work site.

RH-24 - Gradual Return to Work Contract Reimbursement Method: A vocational rehabilitation case manager uses this form when writing a rehab plan that involves returning the injured worker back to work gradually. Gradual return-to-work (GRTW) contracts are offered to employers whose injured workers return to work at reduced hours with gradual progression to full-time work. This contract is an agreement between the employer, injured worker and vocational case manager that the employer will pay full wages during the injured worker’s participation in the GRTW program and then seek reimbursement from BWC for losses in hours worked (not to exceed 50 percent of the injured worker's wages).

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.

SH-24 - Safety Action Plan: Employers who've completed the Safety Management Self-Assessment (SH-26) should use this form to document steps they plan to take to improve their safety and health processes. Employers should review the results from the SH-26 to identify and prioritize manageable action items that will generate the desired improvements.

SH-26 - Safety Management Self-Assessment: Employers who want to participate in the Grow Ohio, Industry-Specific Safety, Drug-Free Safety, Wellness Grant or .99 EM construction cap programs must complete this form. This assessment is intended to help employers evaluate their safety and claims management systems, and identify opportunities for improvement.

SH-27 - Workplace Wellness Grant Program Application: Employers should use this form to apply for funding to assist them in establishing training and programs to reduce health risk factors specific to their employees.

SH-28 - Application for Industry-Specific Safety Program: Employers should use this form to apply for the Industry-Specific Safety Program which offers a 3-percent discount incentive for completing specific loss-prevention activities.

SI-7 - Self Insurance Renewal Form: Self-insuring employers use this form to indicate their continuance of self-insurance each year.

SI-28 - Filing of Complaint Against Self-Insured Employer: Injured workers or their authorized representatives should use this form to file a complaint against their self-insuring employers for various reasons i.e., compensation not paid biweekly, compensation paid at incorrect rate and medical bills not paid timely.

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. The SI-43 also must accompany this form.

SI-43 - Acknowledgement of the Self-Insured Joint Settlement Agreement and Release: The injured worker and self-insuring employer use this form to acknowledge their agreement to the lump sum settlement as detailed on the SI-42.

SI-44 - Election to Withdraw from the Claims Reimbursement Fund: Per Senate Bill 7, self-insuring employers use this form to withdraw from the claims reimbursement fund. This means BWC will no longer include this cost in their annual assessments.

TWB-1 - Application for Transitional Work Bonus Program: Employers use this form to apply for the Transitional Work Bonus program which offers a back-end bonus of up to 10 percent of the employer's pure premium based on the successful use of transitional work in eligible claims with dates of injury within the program year.

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. Not only do they need to complete and sign, but also the injured employee must sign the form before submitting it to BWC.

TWG-1 - Application for Transitional Work Grant Program: Employers use this form to apply for funds to help them contract with a BWC-accredited transitional work developers to establish a transitional work program in their workplace. Transitional work helps businesses offer injured employees strategies to return them to work as soon as safely possible, and before the worker is 100 percent recovered.

TWG-2 - Transitional Work Reimbursement Request Form: Employers participating in the Transitional Work Grant Program use this form along with the service invoice and grant agreement to request reimbursement from their grant fund.

BWC Service Invoice: Employers participating in the Transitional Work Grant Program must include this form when requesting reimbursement.

TWG-3 - Transitional Work Grant Agreement: Employers participating in the Transitional Work Grant Program must sign this agreement and include it when they request reimbursement.

TWG-4 - Transitional Work Grant Program Corporate Analysis Questionnaire Work Sheet: Employers and transitional work developers should submit this form with the employer's grant plan in lieu of a written corporate analysis narrative. Employers who are not eligible or do not receive a transitional work grant also can use this form in preparation for developing their own transitional work program.

U-3 - Application for Ohio Workers' Compensation Coverage: Employers use this form to establish workers’ compensation coverage in Ohio. Ohio law requires any employer with one or more employees to carry workers’ compensation coverage. Corporate officers are considered employees and are required to have coverage. Independent contractors and subcontractors must obtain coverage for their employees. Workers’ compensation coverage is also required for domestic workers (i.e., baby sitters, lawn-care workers, housekeepers) earning $160 or more from more than one employer during a calendar year. Coverage is elective for sole proprietors, partners, ministers and officers of a family farm corporation.

U-3-ES - Application for Ohio Workers' Compensation Coverage (En Español): Employers use this form to establish workers’ compensation coverage in Ohio. Ohio law requires any employer with one or more employees to carry workers’ compensation coverage. Corporate officers are considered employees and are required to have coverage. Independent contractors and subcontractors must obtain coverage for their employees. Workers’ compensation coverage is also required for domestic workers (i.e., baby sitters, lawn-care workers, housekeepers) earning $160 or more from more than one employer during a calendar year. Coverage is elective for sole proprietors, partners, ministers and officers of a family farm corporation.

U-3E - Application for Exemption from Ohio Workers' Coverage and Waiver of Benefits Employers 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. The religious exemption is only for employees/employers considered: Old Order Amish; New Order Amish; and Mennonite that have been in existence since Dec. 31, 1950. Once approved for this exemption, the employer will no longer be required to pay premiums or assessments on any employees covered by this exemption as of the effective date. However, the employer must continue to: submit a payroll report to BWC every six months; pay the applicable minimum administrative cost; and report payroll and pay premiums and assessments for any employee not covered by this exemption. It is also the responsibility of the employer to notify BWC, within 30 days, if the employer is no longer designated as a member of the religious group or no longer follows the established teachings of the religious group. From that date forward the employer is responsible for all premiums and assessments or for self-insuring employers paying compensation and benefits directly.

U-3S - Application for Elective Coverage: Ohio law excludes certain employer types from the definition of an employee. Sole proprietors/partners, ministers of a religious organization, officers of a family farm corporation and owners/members of limited liability companies being treated as a sole proprietorship or partnership for income tax purposes are not required to carry coverage on themselves. Ohio law does make this coverage optional and these individuals may elect coverage for themselves by submitting the completed Application for Elective Coverage.

U-3S-ES - Application for Elective Coverage (En Español): Ohio law excludes certain employer types from the definition of an employee. Sole proprietors/partners, ministers of a religious organization, officers of a family farm corporation and owners/members of limited liability companies being treated as a sole proprietorship or partnership for income tax purposes are not required to carry coverage on themselves. Ohio law does make this coverage optional and these individuals may elect coverage for themselves by submitting the completed Application for Elective Coverage.

UA-3 - Professional Employer Organization Client Relationship Notification: Professional employer organizations (PEOs) should use this form to notify BWC of any new clients, changes in client relationships or termination of clients.

U-19 - Public Employer Agreement for 100-percent EM Cap: Eligible public employers must complete and return this form to us by March 31 to indicate whether they plan on participating in the 100-percent EM cap. They must also indicate who they'll work with to ensure compliance with requirements, either a BWC representative or BWC-certified, 10-Step Business Plan for Safety sponsor. For employers who do not meet requirments, we will calculate their rates using their uncapped EM for the policy year.

U-20 - Application for Retrospective Rating Plan for Private Employers: Private employers use this form to apply for the retrospective rating plan, an alternative rating plan that allows them to initially pay BWC less payroll premium. Private employers must file the application 90 days before the beginning date of the policy year. Private employers must file the application on a yearly basis to continue the plan in subsequent years.

U-21 - Application for Retrospective Rating Plan for Public Employers: Public employers use this form to apply for the retrospective rating plan, an alternative rating plan that allows them to initially pay BWC less payroll premium. Public employers must file the application 90 days before the beginning date of the policy year. Public employers must file the application on a yearly basis to continue the plan in subsequent years.

U-69 - Contract for Coverage of State Agency or Political Subdivision: Public employers use this form to obtain optional workers' compensation coverage for individuals not considered employees (e.g., volunteers, inmates on work detail, convicted individuals performing community service, etc.).

U-80 - Apprenticeship Elective Coverage Contract: Apprenticeship organizations use this form in conjunction with the Application for Ohio Workers' Compensation Coverage (U-3) to formalize a contract with BWC to elect workers’ compensation coverage for its non-employee students who are enrolled and participating in an approved apprenticeship training program as if they were the employer. Apprentices in an approved apprenticeship organization are not considered employees for workers’ compensation purposes. However, an apprenticeship organization may cover the non-employee pre-apprentices, entry-level trainees and journeyman trainees through elective coverage via this form.

U-108 - Agreement for Construction EM .99 Cap: Eligible construction industry employers must complete and return this agreement to BWC by Sept. 30 of the rating year of participation to officially state their intention to opt out of the program. Otherwise, they will automatically receive the temporary experience modifier (EM) of .99 and be responsible for submitting a safety program implementation plan to BWC. Note: BWC provides this EM cap to assist employers when bidding for commercial construction projects. This will not change your actual rates. BWC calculates your actual rates based on your claim experience consistent with the calculations we use for all Ohio employers.

U-117 - Notification of Policy Update: Employers should use this form to notify BWC of changes to the information on their Ohio workers’ compensation policies (e.g., update business information, address/contact information, request to cancel elective coverage and request to cancel Ohio workers’ compensation coverage).

U-118 - Notification of Acquisition/Merger or Purchase Sale: Employers should use this form to send notice to BWC when an existing business was acquired or purchased. BWC will use the information provided to determine what action is required (e.g., successor is liable for former employer’s financial and experience obligations, etc.). If the succeeding employer does not have Ohio workers’ compensation coverage, the succeeding employer is required to also complete the Application for Ohio Workers’ Compensation Coverage (U-3).

U-131 - Notice of Election to Obtain Coverage from Other States for Employees Working Outside of Ohio: 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 may elect to segregate the payroll they report to other state carriers for these employees by submitting this form along with a copy of the insurance policy.

U-140 - Application for Drug-Free Safety Program: Employers should use this form to apply for the Drug-Free Safety Program, which 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. This program helps an employer improve workplace safety and attempts to deter, detect and take corrective action related to substance use in violation of the employer's written DFSP policy.

U-142 – Drug-Free Self-Assessment Progress Report – SAMPLE: BWC will send a copy of this form to employers participating in the Drug-Free Workplace Program or Drug-Free EZ. Employers should expect to receive this form one month before the submission deadline. They should complete the form and fax it with all required documentation to the number provided. The deadlines are March 31 (if in the July program year) or Sept. 30 (if in the January program year). This SAMPLE form simply demonstrates how to complete the report, which BWC requires annually to report progress and to renew participation at the same or different level.

U-145 – Application for Lump Sum Settlement (LSS) Direct Reimbursement Payment and Rating Program for Public Employer State Agencies: Employers should use this form to apply for the Lump Sum Settlement Direct Reimbursement Payment and Rating Program (LSS Program) which is reserved for public employer state (PES) agencies that are not currently participating in a settlement payment program. The LSS Program allows PES agencies not participating in a settlement program to exclude lump sum settlement payments from the rate calculation process. To apply for the July 1 program year, state agencies must submit the form to BWC prior to the Jan. 1 immediately preceding the program year.

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.

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.


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