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OhioBWC - Employer - Form(BWC Forms) - Employer Forms Home

Employer Forms

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BWC # Form Title Description View/ Print Online Order
300APSummary of Work-Related Injuries and IllnessDescription pdf Print Online Form  
AC-18Labor Lease Transaction - Payroll pdf Print   
AC-19Labor Lease Transaction - Claims pdf Print   
AC-2Permanent AuthorizationDescription pdf Print Online Form 
AC-3Temporary Authorization to Review InformationDescription pdf Print  
AC-3-ESTemporary Authorization to Review Information (En Español)Description pdf Print   
C-9-ARequest for Additional Medical Documentation for C-9Description pdf Print  
C-11ADR Appeal to the MCO Medical Treatment/Service DecisionDescription pdf Print Online Form 
C-18Wage AgreementDescription pdf Print  
C-30Request for Medical InformationDescription pdf Print   
C-55Salary Continuation AgreementDescription pdf Print   
C-59Self-Insurer's Agreement as to Compensation on Account of DeathDescription pdf Print  
C-86MotionDescription pdf Print Online Form 
C-86-ESMotion (En Español)Description pdf Print   
C-94-AWage StatementDescription pdf Print  
C-101Authorization to Release Medical InformationDescription pdf Print  
C-108Waiver of AppealDescription pdf Print Online Form 
C-110Employer/Employee Agreement to Select Ohio as the State of Exclusive Remedy for Workers’ Compensation Claims pdf Print  
C-112Employer/Employee Agreement to Select a State Other Than Ohio as the State of Exclusive Remedy for Workers’ Compensation Claims pdf Print  
C-159Waiver of Workers' Compensation Benefits for Recreational or Fitness Activities pdf Print  
C-174Self-Insured Semiannual Report of Claim PaymentsDescription pdf Print   
C-240Settlement Agreement and Application for Approval of Settlement AgreementDescription pdf Print Online Form 
C-240-AClaimant’s Notice of Exception to Employer’s Signature Requirement pdf Print  
C-241Amended Settlement Agreement and Release pdf Print  
CHP-4AApplication for Handicap ReimbursementDescription pdf Print  
DFSP-1DFSP Accident ReportDescription pdf Print Online Form  
DFSP-3Drug-Free Safety Program (DFSP) Annual Report – Basic and Advanced Levels (sample)Description pdf Print Online Form  
DFSP-4Drug-Free Safety Program (DFSP) Annual Report - Comparable Program Only (sample)Description pdf Print Online Form  
DFSP-5DFSP Safety Action PlanDescription pdf Print Online Form  
FROIFirst Report of an Injury, Occupational Disease or DeathDescription pdf Print Online Form 
FROI-ESFirst Report of an Injury, Occupational Disease or Death (En Español)Description pdf Print   
Reporting fraudDescription  Online Form  
IC-167-TObjection to Tentative Order Awarding Permanent Partial DisabilityDescription pdf Print   
LEGAL-16Settlement Application for Non-complying Employer ClaimsDescription pdf Print   
MCO Selection FormDescription pdf Print Online Form  
MEDCO-6Waiver of Examination Statewide Disability Evaluation SystemDescription pdf Print  
MEDCO-8Self Insured Employer/Injured Worker ScreeningDescription pdf Print  
OCP-1Application for One Claim ProgramDescription pdf Print Online Form  
OD-58-22Application for Adjustment of Claim in Case of Death Due to Occupational DiseaseDescription pdf Print   
R-1Employer Authorized RepresentativeDescription pdf Print Online Form 
R-4Application for Representative Identification Number Description pdf Print   
RH-5Trainer's ReportDescription pdf Print  
RH-6On-the-Job Training AgreementDescription pdf Print  
RH-19Employer Incentive ContractDescription pdf Print  
RH-24Gradual Return to Work Contract Reimbursement MethodDescription pdf Print  
RPS-Amend-PayrollAmended Payroll Report pdf Print   
SA-5Self-Assessment for the 10-Step Business Plan for SafetyDescription pdf Print   
SH-6PERRP Complaint Form pdf Print   
SH-12Sharps Injury Form - Needlestick ReportDescription pdf Print Online Form  
SH-26Safety Management Self-AssessmentDescription pdf Print Online Form  
SH-27Application for Workplace Wellness Grant ProgramDescription pdf Print Online Form  
SH-28Application for Industry-Specific Safety ProgramDescription pdf Print Online Form  
SH-29Industry-Specific Safety Program Post on-site consultation surveyDescription pdf Print Online Form  
SI-6Initial Application by Employer for Authority to Pay Compensation Etc. Directly pdf Print   
SI-7Application for Renewal of Authorization to Operate as a Self-insured PolicyDescription  Online Form  
SI-8Rehabilitation Election pdf Print   
SI-16Agreement Between Employer and the Ohio Bureau of Workers' Compensation Regarding Amount of Self-Insured Buyout pdf Print   
SI-28Filing of An Allegation Against a Self-Insured EmployerDescription pdf Print Online Form 
SI-38Contract of Guaranty pdf Print   
SI-40Report of Paid Compensation and Case Reserves pdf Print Online Form  
SI-41Handicap Reimbursement Election pdf Print   
SI-42Self Insured Joint Settlement Agreement and ReleaseDescription pdf Print  
SI-43Acknowledgment of the Self-Insured Joint Settlement Agreement and ReleaseDescription pdf Print  
SI-44Election to Withdraw from Claims Reimbursement Fund pdf Print   
SI-50Self-Insured Construction Wrap-Up Appplication pdf Print   
SI-51Application for Certification of Qualified Health Plan (QHP) pdf Print   
SI-52Self-Insured Claims Reimbursement (Sysco) Appplication pdf Print   
Subrogation Referral Form pdf Print   
TWB-1Application for Transitional Work Bonus ProgramDescription pdf Print Online Form  
TWB-2Transitional Work Offer and Acceptance FormDescription pdf Print Online Form  
TWG-1Application for Transitional Work Grant ProgramDescription pdf Print Online Form  
TWG-2Transitional Work Grant Reimbursement Request FormDescription pdf Print   
BWC Service InvoiceDescription pdf Print   
TWG-3Transitional Work Grant AgreementDescription pdf Print   
TWG-4Transitional Work Grant Program Corporate Analysis Questionnaire Work SheetDescription pdf Print   
U-3Application for Ohio Workers' Compensation CoverageDescription pdf Print Online Form 
U-3-ESApplication for Ohio Workers' Compensation Coverage (En Español)Description pdf Print   
U-3EApplication for Exemption from Ohio Workers’ Coverage and Waiver of BenefitsDescription pdf Print   
U-3SApplication for Elective CoverageDescription pdf Print Online Form 
U-3S-ESApplication for Elective Coverage (En Español)Description pdf Print   
UA-3Professional Employer Organization Client Relationship NotificationDescription pdf Print   
UA-610-Step Business Plan of ActionDescription pdf Print   
U-19Public Employer Agreement for 100-percent EM CapDescription pdf Print   
U-20Application for Retrospective Rating Plan for Private EmployersDescription pdf Print Online Form  
U-21Application for Retrospective Rating Plan for Public EmployersDescription pdf Print Online Form  
U-69Contract for Coverage of State Agency or Political SubdivisionDescription pdf Print   
U-80Apprenticeship Elective Coverage ContractDescription pdf Print   
U-108Opt Out of .99 EM Construction Cap ProgramDescription pdf Print   
U-117Notification of Policy UpdateDescription pdf Print Online Form 
U-118Notification of Business Acquisition/Merger or Purchase/SaleDescription pdf Print Online Form 
U-131Notice of Election to Obtain Coverage from Other States for Employees Working Outside of OhioDescription pdf Print   
U-140Application for Drug-Free Safety ProgramDescription pdf Print Online Form 
U-145Lump Sum Settlement (LSS) Direct Reimbursement Rating and Payment Program for Public Employer State AgenciesDescription pdf Print   
U-147Non-Ohio Amended Payroll Report pdf Print   
U-148Application for Deductible ProgramDescription pdf Print Online Form  
U-149Sponsor Certification ApplicationDescription pdf Print   
Extended Payment PlanDescription pdf Print   



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