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OhioBWC - Common - Form: (C-140) - Introduction

Application for Wage Loss Compensation
(C-140)
Introduction
The injured worker and the physician of record must complete this form for the injured worker to apply for wage loss compensation. While you may complete the C-140 online, you must print it off after completion to submit either by mail or fax.

Required information
Injured worker
  • Claim number
  • Name
  • Address
  • Phone number
  • Date of birth
  • Social Security number
  • Occupation at time of injury
  • Injury employer's name, address and phone number
  • Dates and type of wage loss being applied for
  • Work history information including: employer names, dates of employment, job titles, reasons for leaving and earnings
Physician
  • Name
  • Address
  • Telephone number
  • Injured worker information including: date of last medical examination, restrictions (permanent and/or temporary) as a result of the allowed conditions in the claim, duration of temporary restrictions (if applicable), and any other restrictions (not related to claim)
  • Injured worker physical capacity for: sitting, standing, and walking; bending, squatting, crawling, climbing, reaching; lifting; carrying; use of hands in repetitive actions such as grasping, pushing and pulling arm controls, and fine manipultation; and use of feet in repetitive movements of leg controls

Complete the form

If you have all the required information on hand, simply click the start button to begin.

Start

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