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.

AC-2-ES - Autorización permanente: Un empleador o representante del empleador puede presentar este formulario en línea siempre y cuando haya una copia impresa de la AC-2 en el lugar del empleador. Esta autorización sustituirá a todas las autorizaciones permanentes en el expediente para el tipo de representante elegido.

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: 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 - Autorización temporaria para la revisión de la información: Los empleadores deben usar este formulario para permitir que administradores de tercera parte revisen y trabajen, en su nombre, en determinados temas en sus pólizas de compensación a trabajadores.

AC-4 - Request for Business Transfer Information: An employer 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.

AC-28 - Request to Charge the Surplus Fund for Non-At-Fault Motor Vehicle Accident: This application details the required documentation a private employer or public employer taxing district must provide to support a request for experience modification calculation. BWC will advise you if it needs additional documentation or information.

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-11-ES - Apelación a la decisión por servicio/tratamiento médico de la MCO de ADR: Los trabajadores lesionados, empleadores, proveedores de servicios médicos o los representantes autorizados deben usar este formulario para apelar la decisión de la organización de atención administrada (Managed Care Organization, MCO) con respecto al servicio o tratamiento. Este formulario inicia el proceso de resolución alternativa de disputa (Alternative Dispute Resolution, ADR).

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.

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 - Moción: Cualquier individuo de la reclamación puede usar este formulario para solicitar acciones en una reclamación por parte de BWC o la IC (por ej., que se permitan condiciones y/o pagos por beneficios adicionales). Este formulario siempre debe enviarse con documentación comprobante que demuestran pruebas médicas.

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 - Request for 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-108-ES - Renuncia al período de apelación : Los trabajadores lesionados, empleadores o sus respectivos representantes deben usar este formulario para renunciar a los derechos de apelación a una orden de la BWC o de la IC. Ambas partes deben firmar la petición para renunciar (o cancelar) al período de apelación. Una renuncia firmada por solo una de las partes no cancelará un período de apelación.

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-142 - Employer Report of Employee Earnings for Wage Loss Compensation: 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-159-ES - Renuncia a los beneficios por indemnización de los trabajadores para actividades recreativas o de ejercicios físicos: Los trabajadores lesionados completan este formulario para renunciar a la cobertura de indemnización de los trabajadores para participar voluntariamente en actividades recreativas o programas de ejercicios físicos patrocinados por el empleador.

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.

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.

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.

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.

CHP-4A - Application for Disability 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 disability condition or the aggravation of a pre-existing disability condition. The form includes a schedule of the qualifying disability 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 - Informe inicial de lesión, enfermedad ocupacional o fallecimiento : Ios trabajadores lesionados, los empleadores o los proveedores de atención médica usan este formulario para iniciar una reclamación de compensación debido a un accidente de trabajo. Cualquier individuo que complete el formulario debe proporcionar a BWC información lo más detallada que sea posible.

LEGAL-15 - Application for Adjudication Hearing: Employers or employer 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.

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 and public employer taxing districts use this form to apply for the One Claim Program.

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.

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-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.

BWC Implementation Invoice: Employers who use implementation services 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 - Solicitud de Cobertura bajo el seguro de accidentes de trabajo de Ohio: os empleadores usan este formulario para establecer la cobertura de compensación por accidente de trabajo de uno o más empleados en Ohio. Las leyes de Ohio establecen que cualquier empleador con uno o más empleados debe proporcionar cobertura por accidentes de trabajo. Los contratistas y subcontratistas independientes deben obtener cobertura para sus empleados. También se requiere cobertura por accidentes de trabajo para empleados domésticos (por ej., niñeras, jardineros, amas de llaves) que ganen $160 o más, de más de un empleador durante un año calendario.

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 - Solicitud de Cobertura electiva: Las leyes de Ohio excluyen a algunos tipos de empleadores de la definición de un empleado. No es necesario que los propietarios/socios únicos, ministros de una organización religiosa, directores de una empresa rural familiar ni los miembros/propietarios de una sociedad de responsabilidad limitada que se considere como una propiedad o sociedad individual a fines de los impuestos sobre la renta tengan cobertura para sí mismos. Las leyes de Ohio hacen que esta cobertura sea opcional.

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 by the last business day of January, preceding a policy year that starts July 1. 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 by the last business day in July, preceding a policy year that starts Jan. 1. Public employers must file the application on a yearly basis to continue the plan in subsequent years.

U-59 - Request for Retroactive Coverage and Penalty Abatement or Waiver of Payroll True-Up Penalties: Employers or their representatives use this form to request retroactive coverage and penalty abatement for a lapse in coverage or a waiver of payroll true-up penalties. The employer's lapse duration must be 59 days or less, or the employer must have completed payroll true-up within 59 days of the grace period, for the administrator to grant the request. Ohio Administrative Code (OAC) 4123-14-03 allows BWC's administrator to approve retroactive coverage and penalty abatement or waive payroll true-up penalties if an employer can show good cause for late payment and/or late reporting. An employer may request a one-time forgiveness under OAC 4123-14-03 if the employer cannot show good cause for late payment and/or late reporting.

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-115 - Request to Transfer Existing Coverage to Succeeding Employer: This form is used when the succeeding employer wishes to maintain the existing policy of the predecessor employer and must be signed by both parties. It is not to be used to combine two or more insureds who both have an active policy. If coverage already exists for the succeeding employer, STOP, you must complete form U-118, Notification of Purchase/Sale or Merger Acquisition. Some exceptions may apply. Please call for more details..

U-116 - Notification to Add/Remove an Additional Named Insured(s): This form is to request the addition or removal of an Additional Named Insured. This should only be used if the ownership of each entity is identical to the ownership on the existing policy and/or across ALL entities. Requests to add entities with different reporting requirements for owners and officers from that of the existing policy, will not be granted.

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-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.

WAGES-EMP-ES - Informe del empleador de ingresos del empleado: Los empleadores completan este formulario para proporcionar la documentación de los ingresos de un empleado lesionado específico para ayudar a la BWC a establecer los salarios por beneficios de indemnización. Deben completar la sección de la planilla de siete días de trabajo y luego, ya sea completar y firmar la hoja de declaración de ingresos o enviar un informe de nómina que inicie con el período de pago completo que terminó antes de la fecha de la lesión o la fecha de la incapacidad en un reclamo por enfermedad laboral.