OhioBWC - Common - Form:  (SI-28) - Introduction

Filing Of Allegation Against A Self-Insured Employer

Injured workers who believe their self-insuring employer is not or has not handled their claim appropriately may file a complaint using this form. For a complaint to be valid, the employer must have violated a workers' compensation rule or law. Whhile you can fill out the SI-28 online, you must download and print the form, include any supporting documentation, and mail or fax it to the self-insured department.

Note: We'll provide a copy of this allegation to the employer along with a request for a response. By law, the employer must respond to the self-insured department within 14 days of the date it receives notice of the complaint.

Required information
Injured worker
  • Injured worker name: first, middle, last
  • Social Security number
  • Mailing address
  • Employer name
  • Mailing address
  • Telephone number
Employer contact (if applicable)
  • Date of contact
  • Contact person
  • Description of your concern
  • Employer response

Complete the forms

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