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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-2Request to Add/Change or Terminate Permanent AuthorizationDescription pdf Print Online Form 
AC-2-ESAutorización permanenteDescription pdf Print   
AC-3Temporary Authorization to Review InformationDescription pdf Print Online Form  
AC-3-ESAutorización temporaria para la revisión de la informaciónDescription pdf Print   
AC-4Request for Business Transfer InformationDescription pdf Print   
AC-28Request to Charge the Surplus Fund for Non-At-Fault Motor Vehicle AccidentDescription 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-11-ESApelación a la decisión por servicio/tratamiento médico de la MCO de ADRDescription pdf Print   
C-18Notice to BWC of the Injured Worker and Employer Agreement and Authorization to Send Injured Worker's Check(s) to the EmployerDescription 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-ESMociónDescription pdf Print   
Wages-EMPEmployer Report of Employee Earnings - formerly Wage Statement (C-94A) pdf Print Online Form  
Wages-EMP-ESInforme del empleador de ingresos del empleadoDescription pdf Print   
C-101Authorization to Release Medical InformationDescription pdf Print  
C-101-ESAutorización para divulger información médica 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-142Employer Report of Employee Earnings for Wage Loss CompensationDescription pdf Print  
C-159Waiver of Workers' Compensation Benefits for Recreational or Fitness Activities pdf Print  
C-159-ESRenuncia a los beneficios por indemnización de los trabajadores para actividades recreativas o de ejercicios físicos Description 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-262Self-Insured Employer's Certification of Assignment After Initial AllowanceDescription pdf Print   
C-263State Fund Employer's Agreement to Accept Claim AssignmentDescription pdf Print   
C-264Request to Correct Employer and/or Policy Number AssignmentDescription pdf Print   
C-512Notice of intent to Settle pdf Print   
CHP-4AApplication for Disability ReliefDescription 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  
DFSP-6Application for the Drug-Free Safety Program Vendor Directory pdf Print   
FROIFirst Report of an Injury, Occupational Disease or DeathDescription pdf Print Online Form 
FROI-ESInforme inicial de lesión, enfermedad ocupacional o fallecimientoDescription pdf Print   
Reporting fraudDescription  Online Form  
IC-12Ohio Industrial Commission Notice of Appeal pdf Print   
IC-167-TObjection to Tentative Order Awarding Permanent Partial DisabilityDescription pdf Print   
LEGAL-15Application for Adjudication HearingDescription 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  
PERRP-7PERRP Fatality reporting form pdf Print Online Form  
PERRP-8PERRP Serious injury reporting form pdf Print Online Form  
R-1Employer Authorized RepresentativeDescription pdf Print   
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 P/RAmended True-Up Payroll Report pdf Print   
Certification safety agreement for sponsors and affiliate sponsors pdf Print   
SH-2Division of Safety & Hygiene Group Experience-and Group-Retrospective-Rating Safety Requirements Annual Report pdf Print   
SH-6PERRP Complaint Form pdf Print Online Form  
SH-12Sharps Injury Form - Needlestick ReportDescription pdf Print Online Form  
SH-26Safety Management Self-AssessmentDescription pdf Print Online Form  
Request for safety and health consultation form  Online Form  
OSHA On-Site Consultation Request Form  Online Form  
PERRP Compliance Assistance Request  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-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-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) Application pdf Print   
Subrogation Referral Form pdf Print   
SUR-1Substance Use Recovery and Workplace Safety Program Enrollment Form  Online Form  
SUR-2Substance Use Recovery and Workplace Safety Program Request for Reimbursement pdf Print   
SUR-3Substance Use Recovery and Workplace Safety Program Agreement pdf Print   
TWB-1Application for Transitional Work Bonus ProgramDescription pdf Print Online Form  
TWB-2Transitional Work Offer and Acceptance FormDescription pdf Print Online Form  
TWB-2-ESFormulario de oferta laboral de transición y aceptación pdf Print   
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   
BWC Implementation 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 Coverage pdf Print Online Form 
U-3-ESSolicitud de Cobertura bajo el seguro de accidentes de trabajo de OhioDescription pdf Print   
U-3EApplication for Exemption from Ohio Workers' Coverage and Waiver of BenefitsDescription pdf Print   
U-3E-ESSolicitud para la Exención de la Cobertura de la Indemnización de los Trabajadores de Ohio y Renuncia de los Beneficios pdf Print   
U-3SApplication for or Request to Cancel Elective CoverageDescription pdf Print Online Form  
U-3S-ESSolicitud de Cobertura electivaDescription pdf Print   
UA-3Professional Employer Organization Client Relationship NotificationDescription pdf Print   
UA-3 SISelf-Insured Professional Employer Organization (PEO) Client Relationship Notification 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-59Request for Retroactive Coverage and Penalty Abatement or Waiver of Payroll True-Up PenaltiesDescription pdf Print   
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-114Request to Cancel Workers' Compensation Coverage pdf Print   
U-115Request to Transfer Existing Coverage to Succeeding Employer pdf Print   
U-116Notification to Add/Remove an Additional Named Insured(s) 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   
U-157Request to Exclude Work-Based Learning Pilot Program Claims from Employer's ExperienceDescription pdf Print   
U-158Pre-audit Questionnaire and Employer's Authorization pdf Print   
U-158-ESCuestionario previo a la auditoria pdf Print   
U-159Other States Coverage - Trucking Supplemental Application pdf Print   
U-160Fall Protection in Construction Supplemental Questions pdf Print