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

Application for Wage Loss Compensation
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
  • 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.