OhioBWC - Common - Form:  (C-86)- Introduction


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). Generally, this form should always be submitted with supporting documentation such as medical evidence. If this is the case, we suggest that you not submit this form electronically.

However, you can complete the form online, print it and then mail or fax to BWC with your supporting documentation.

Whether completing online or hard copy, the applicant will be asked to certify that copies of the Motion have been served on all parties and representatives to the claim.

Note: Health- care providers and/or managed care organizations are not parties to the claim and should use the Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Accident or Occupational Disease (C-9) to request action.

Required information
  • Explanation of what action is being requested
  • Explanation of supporting evidence (affidavits, medical records, reference to information already on file or narrative documentation)
  • Name of person completing form

Complete the forms
The free Adobe Reader software is required to display and print the application.

Do you have all the required information at hand? If so, you are ready to begin completing the form. When completing the online form, please use the previous and next buttons located at the bottom of the page to navigate through the form.
Begin online form now.

Are you missing some of the required information? If so, you may return here at a later time when you have all the information you need, and complete this online form. Or, you may print a blank copy of the form to complete by hand and either mail or fax it to the BWC.
Print a blank form.