OhioBWC - Worker - Form: (BWC Forms) - Injured Worker Forms Descriptions | ||||
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Injured worker forms descriptions |
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A-12 EFT - A.C.T. Enrollment Form and Direct Deposit Authorization:
Injured workers should use this form to apply for direct deposit of their workers' compensation payments. Automatic Comp Transfer (ACT)
deposits injured worker compensation payments into a checking or savings account of their choice on the day payment is due.
Injured workers must send the form along with a voided check or personal deposit slip containing the banking information and
account number to BWC ACT, P.O. Box 15429, Columbus, OH 43215-0429.
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A-12-ES EFT - Formulario de inscripción y
autorización de depósito directo de la ACT:
Los trabajadores lesionados deben usar este formulario para solicitar un depósito directo de sus pagos de indemnización
a los trabajadores. La transferencia de compensación automática (Automatic Comp Transfer, ACT)
deposita los pagos de indemnización del trabajador lesionado en una cuenta corriente o de ahorros de su elección
el día de pago. Los trabajadores lesionados deberán enviar el formulario junto con un cheque anulado
o un recibo de depósito personal que contenga la información bancaria y número de cuenta a BWC ACT, P.O. Box 15429,
Columbus, OH 43215-0429.
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A-21 - Prepaid Debit Card Enrollment Application: 1. You are generally protected from all liability for unauthorized transactions with Zero Liability. You must call the number on the back of your card immediately to report any
unauthorized use. Certain conditions and limitations may apply. See your Cardholder Agreement for details. |
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A-21-ES - Solicitud de inscripción para la tarjeta de beneficios prepagada:
Los trabajadores lesionados que reciben beneficios por incapacidad total y permanente son elegibles para una tarjeta de beneficios prepagada después de recibir y leer
la divulgacion previa a la adquisición. Con la tarjeta prepagada, los trabajadores lesionados tendrán sus beneficios anadidos a su
cuenta automáticamente. Trabajadores lesionados podrán hacer compras, obtener efectivo, y pagar facturas en cualquier lugar donde se
acepta Visa®. Fondos en la tarjeta de Visa® prepagada son protegidos si la tarjeta se pierde o si es robada. 1. Generalmente, usted sera protegido de toda responsabilidad por transacciones no autorizadas con Zero Responsabilidad. Usted debe llamar al número en la parte de atrás de su tarjeta inmediatamente para reportar cualquier uso no autorizado. Ciertas condiciones y limitaciones podrán aplicar. Revise su Acuerdo de Tarjetahabiente para detalles. La ReliaCard® es emitida por la Asociación Nacional de U.S. Bank (U.S. Bank National Association) en virtud de una licencia de Visa U.S.A. Inc. © 2022 U.S. Bank Member FDIC |
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A-35 - Direct Deposit ACT Bank Change:
Injured workers should use this form to change the bank where BWC deposits their compensation benefits. Automatic Comp Transfer (ACT)
deposits workers' compensation payments into the injured worker's checking or savings account on the day it's due. Fill out the form
completely and attach a voided check or deposit slip for the new account. Send the form to BWC Benefits Payable, P.O.
Box 15429, Columbus, OH 43215-0429.
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A-35-ES - Cambio de banco de depósito directo de ACT:
ILos trabajadores lesionados deben usar este formulario para cambiar el banco donde la BWC deposita sus beneficios
de indemnización. La transferencia de compensación automática (Automatic Comp Transfer, ACT)
deposita los pagos de indemnización de los trabajadores en una cuenta corriente o de ahorros el día de pago.
Complete el formulario y adjunte un cheque anulado o un recibo de depósito para la cuenta nueva. Envíe el formulario
a BWC Benefits Payable, P.O. Box 15429, Columbus, OH 43215-0429.
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C-5 - Application for Death Benefits and/or Funeral Expenses:
This form is used to supply BWC with additional information when benefits are being requested on account of the death of an injured
worker. Information requested pertains to an injured worker's dependent(s) or other person(s) who have paid for services related to the
injured worker's death.
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C-5-ES - Solicitud para los beneficios por fallecimiento y/o gastos funerarios:
Este formulario se utiliza para proporcionar a la BWC información adicional cuando los beneficios son solicitados a causa de la
muerte de un trabajador lesionado. La información solicitada se refiere a los dependientes del trabajador lesionado u otras
personas que han pagado por los servicios relacionados con la muerte del empleado lesionado.
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C-6 - Application for Accrued Compensation:
Those eligible for benefits after an injured worker's death can use this form to apply for compensation that was unpaid at the time of
the decedent's death.
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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.
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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).
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C-17 - Request for Injured Worker Outpatient Medication Reimbursement:
Injured workers should use this form to get reimbursed for prescribed outpatient medication only. This form is not used for
medical supplies, durable medical equipment (crutches, walkers, etc.), and other non-drug items reqardless of the provider type that
supplied them. Pharmacy providers are expected to submit bills to ACS State Healthcare electronically, even before the injured worker
has a claim number. As a result, the use of the C-17 should be rare and limited to special circumstances. Before filling out the form,
read all the instructions at the top carefully. You can obtain all the information you need to complete the form at your pharmacy.
You should send the completed C-17 to ACS State Healthcare with the medication receipts and pharmacist signature. Injured workers whose employers are self-insuring should contact their employers for instructions on billing for outpatient medications. ACS State Healthcare is not responsible for processing bills in self-insuring claims. |
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C-18 Notice to BWC of the Injured Worker and Employer Agreement
and Authorization to Send Injured Worker's Check(s) to the Employer:
Injured workers can use this form to establish an agreement between BWC, their employers and themselves so BWC will reimburse their
employers for any wages they paid to them while also receiving temporary total benefits from BWC.
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C-23 - Notice to Change Physician of Record:
Injured workers should use this form to notify their managed care organization (MCO) of a change of physician. Injured workers must
choose a physician who is BWC-certified. The physician will receive payment only for medical services and items related to the treatment
of the allowed conditions in the injured workers claim and in accordance with the MCO's medical management guidelines. Injured worker's
can also use this form to notify self-insuring employers of a change of physician.
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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.
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C-32 - Application for Payment of Lump Sum Advancement
Injured workers or their dependents should use this form to request an advanced payment of their workers' compensation benefits. Injured workers must attach
documentation to support the request. They should not use this form to request a lump sum payment for attorney fees.
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C-60 - Completing the Injured Worker Statement for Reimbursement of Travel Expense:
Injured workers use this form to request reimbursement for travel expenses incurred relative to a medical exam or treatment for a work-related injury or
disease. Injured workers should send the completed form to BWC or their self-insuring employer.
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C-60-A - Injured Worker Reimbursement Rates for Travel Expense:
A companion to the C-60, this form explains the reimbursable rates for travel-related expenses. Rates apply to the dates the expenses are incurred.
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C-72 - Authorization to Release Information:
Injured workers use this form to give permission to an authorized representative to review some or all of his or her claim information.
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C-72-ES - Autorización para divulgar información:
Los trabajadores lesionados utilizan este formulario para darle permiso a un representante autorizado para revisar parte o toda la información de su reclamo.
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C-77 - Injured Worker's Change of Address Notification:
Injured workers use this form to notify BWC or their self-insuring employer of a new address and phone number.
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C-84 - Request for Temporary Total Compensation:
Injured workers must use this form to initiate or extend payment of temporary total disability benefits. The injured worker provides
information about employment and benefits received during the time of disability. The physician provides information about the condition, physical
restrictions, objective and subjective findings, maximum medical improvement, vocational rehabilitation and the dates of disability being certified, including
an estimated or actual return-to-work date via the MEDCO-14 form. This form advises the injured worker of the penalties associated with
workers' compensation
fraud.
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C-84-ES - Petición de compensación total temporal:
Los trabajadores lesionados y sus médicos deben usar este formulario para iniciar y extender el pago de beneficios por incapacidad total temporaria.
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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.
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C-86-ES - 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.
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C-92 - Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability:
Injured workers should use this form to request an award for permanent impairment, either physical or psychological, resulting from an allowed workers' compensation claim. If an injured worker has a permanent impairment,
he or she may be eligible for a monetary award based upon the severity of the impairment. The injured worker may be eligible for this award even if he or she did not lose time from work due to the injury. |
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C-92-ES - Solicitud para determinar el porcentaje de
incapacidad parcial permanente o aumento de la incapacidad permanente parcial:
Los trabajadores lesionados deben usar este formulario para solicitar una determinación relativa a una incapacidad permanente
que tienen como consecuencia de su lesión o enfermedad relacionada al trabajo. La solicitud
inicial de incapacidad parcial permanente puede presentarse en las 40 semanas después de la fecha de la lesión (o después
de la última fecha de indemnización por incapacidad) reclamos que sucedieron antes del 30, junio del 2006. Para reclamos
que sucedieron después del 30, junio del 2006, la solicitud inicial no debe ser presentada antes de 26 semanas después.
No existe ninguna limitación de tiempo para la presentación de un aumento.
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C-101 - Authorization to Release Medical Information: Injured workers should use this form to authorize the release of medical records relative to their work-related injury(s). By signing this form, the injured worker authorizes medical providers who have rendered services relative to the injury to 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. Medicaid Medical Release Form (ODM 10221) - alternative Pursuant to Ohio Administrative Code 5160-1-32.1 if the Medicaid standardized authorization form is properly filled out and identifies the individual in section I of the form by either an individual or their personal representative, the form shall be accepted by ANY person or governmental entity in this state as valid authorization for the use or disclosure of the individual's protected health information to requestor specified on the form. That means the Medicaid form will reduce the need for a party to use multiple provider specific medical release forms. So, both the C-101 and the Medicaid form will facilitate and support action related to addressing claim released issues. |
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C-108 - Request For Waiver of Appeal:
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.
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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.
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C-140 - Application for Wage Loss Compensation:
Injured workers use this form to apply for wage loss compensation. Injured workers may be eligible for wage loss if they are working with restrictions and
earning less than before the injury or disease. They may also be eligible if they are actively seeking but are unable to find work within their physical
capabilities. This form is completed by the injured worker and the physician of record. The injured worker supplies information regarding the current work
status and employment history. The physician provides information regarding the injured worker's work restrictions and physical capacity. Completed forms should
be sent to BWC or the self-insuring employer.
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C-141 - Wage Loss Statement for Job Search:
Injured workers who have already applied for or are receiving wage loss use this
form to document the employers they contact during weekly job searches and the
results. BWC bases eligibility for non-working wage loss compensation on
evidence of their continued job search efforts. Completed forms should be sent
to BWC or the self-insured employer.
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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.
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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.
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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.
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C-230 - Authorization to Receive Workers' Compensation Check:
Injured workers use this form to authorize BWC to send their workers'
compensation checks to their attorneys or authorized representatives. BWC
encourages them to read the time frames on the form before signing it.
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C-230-ES - Autorización para recibir Cheques de compensación por accidentes en el trabajo:
Los trabajadores lesionados usan este formulario para autorizar que BWC envíe los cheques de compensación por accidente de trabajo
a sus abogados o representantes autorizados. BWC los anima a leer los plazos que figuran en el formulario antes de firmar.
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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-insured employers should use the self-insuring
application, the SI-42.
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C-255 - Affidavit for Attorney Fees:
Attorneys can use this form when requesting reimbursement from BWC for fees owed to them from lump sum
payments to injured workers. The form, which can be used voluntarily, provides a standard format to submit
their request with a signed copy of a written fee agreement.
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Reporting fraud Injured workers 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, injured workers need only to suspect that fraud may have been committed. |
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FROI - First Report of 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.
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FROI-ES - Informe inicial de lesión, enfermedad ocupacional o fallecimiento:
Los 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.
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Request for Prior Authorization of Medication Form (MEDCO-31):
Injured workers' physicians use this form to request prior authorization for medications not typically used
for industrial injuries or occupational diseases. Fax completed MEDCO-31 to ACS State Healthcare's prior
authorization fax number, which is located at the bottom of the form, for processing.
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Request for Prior Authorization of NON-PREFERRED Medication Form (MEDCO-32):
Injured workers' physicians use this form to request prior authorization for medications on BWC's non-preferred
drug list as part of the BWC Preferred Drug Program. Some medications in the following catagories require
authorization: non-steroidal anti-inflammatory drugs (NSAIDs); Cox-2 inhibitors; skeletal muscle relaxants; and
opioid analgesics. Fax completed MEDCO-32 to ACS State Healthcare's prior authorization fax number, which
is located at the bottom of the form, for processing.
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R-2 - Claimant Authorized Representative:
Injured workers and their representatives use this form to notify BWC of the
injured worker's representative.
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R-2-ES - Autorización de un representante del trabajador lesionado:
Los trabajadores lesionados y sus representantes utilizan este formulario para notificar a la BWC sobre el representante del empleado lesionado.
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R-4 - Application for Representative Identification Number:
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RH-1 - Rehabilitation Agreement:
A vocational rehabilitation case manager uses this form to obtain agreement from an injured worker to participate in vocational rehab services. The case manager
should explain vocational rehab and give the agreement to the injured worker during an initial interview. The injured worker must sign the form before
beginning vocational rehab services.
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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.
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RH-7 - Loan/Release Agreement for Tools and Equipment:
The vocational rehabilitation case manager uses this form when purchasing tools or equipment for an injured worker as part of a rehab plan. The case manager
itemizes the tools/equipment (quantity, brand, model, serial number and description) purchased. The form must be signed by the injured worker and
indicates that the tools/equipment are BWC property if the injured worker does not successfully complete training/return to work.
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RH-10 - Vocational Rehabilitation Plan Job Search Contacts:
Injured workers use this form to record job search contacts when participating in job-search rehab plans. Job search is an individualized rehab program for
injured workers who cannot return to their original employers but have transferable skills and the physical capacities to return to the labor force.
The vocational rehabilitation case manager will identify the number of job search contacts the injured worker will be required to make each week.
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RH-18 - Authorization for Living Maintenance Wage Loss:
Injured workers use this form to set up living maintenance wage loss payments with BWC. Living maintenance wage loss off sets decreased
wages when an injured worker returns to work after successful completion of a vocational rehab plan. This type of compensation requires
documentation of the injured worker's current physical restrictions and a date of injury or diagnosis on or after Aug. 26, 1986.
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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).
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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.
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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.
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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.
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WAGES-IW-ES - Declaración de los ingresos del trabajador lesionado:
Los trabajadores lesionados completan este formulario para proporcionar el nombre, la dirección y las fechas de empleo de todos sus empleadores durante las 52 semanas anteriores a la fecha de la lesión o la fecha de la incapacidad
en un reclamo por enfermedad laboral. Si corresponde, incluya la información del trabajo por cuenta propia. Adjunte una hoja adicional o use múltiples copias de este formulario, si fuera necesario. Usted debe enviar la comprobación
de los ingresos reales de estos períodos de empleo a la BWC.
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WAGES-EMP-ES - Dinforme 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.
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