Filing a claim - Applicable forms

• Injured Worker Authorized Representative (R-2)
• Employer Authorized Representative (R-1)
• Authorization to Release Medical Information (C-101)
• Autorización para divulger información médica (C-101-ES)
• Consent to Release Information (C-72)
• ACT Enrollment and Direct Deposit Authorization (A-12)
• EBT - Electronic Benefit Card Enrollment Application (A-21)
• Direct Deposit ACT Bank Change (A-35)
• First Report of an Injury, Occupational Disease or Death (FROI)
• Informe inicial de lesión, enfermedad ocupacional o fallecimiento (FROI-ES)
• Presumption of Causation for Firefighter Cancer (C-265)

Temporary total/Salary continuation - Applicable forms

• Request for Temporary Total Compensation (C-84)
• Petición de compensación total temporal (C-84-ES)
• Physician's Report of Work Ability (MEDCO-14)

Wage loss - applicable forms

• Application for Wage Loss Compensation (C-140)
• Wage Loss Statement for Job Search (C-141)
• Employer Report of Employee Earnings for Wage Loss Compensation (C-142)

Scheduled loss - applicable forms

• Motion (C-86)
• Moción (C-86-ES)
• Amputation/Loss of Use Diagram (C-196)

Percentage of permanent partial - Applicable forms

• Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability (C-92)
• Objection to Tentative Order Awarding Permanent Partial Disability Compensation (C-167-T)
• Agreement as to Compensation for PPD (IC-CG1)

Permanent total disability (PTD)/DWRF - Applicable forms

• Application for Compensation for Permanent Total Disability (IC-2)
• PTD rate calculation worksheet - Instructions
• PTD rate calculation worksheet

Lump sum settlement - Applicable forms

• Settlement Agreement and Application for Approval of Settlement Agreement for state-fund claims only (C-240)
• Medical History and Disclosure (C-242)
• PTD-Death Settlement Acknowledgement and Waiver Full and Final Settlement (C-243)
• Indemnity Only Settlement Acknowledgement and Waiver (C-245)
• Notice of Intent to Settle (C-512)

Lump sum advancement - Applicable forms
Application for Payment of Lump Sum Advancement (C-32)

Wages - Applicable forms

• Injured Worker Earnings Statement (WAGES-IW)
• Declaración de los ingresos del trabajador lesionado (WAGES-IW-ES)
• Employer Report of Employee Earnings (WAGES-EMP)
• Informe del empleador de ingresos del empleado (WAGES-EMP-ES)

Travel reimbursement - Applicable forms

• Completing the Injured Worker Statement for Reimbursement of Travel Expense
• Injured Worker Reimbursement Rates for Travel Expense

Other - Applicable forms

• ADR Appeal to the MCO Medical Treatment/Service Decision (C-11)
• Notice to Change Physician of Record (C-23)
• Injured Worker's Change of Address Notification (C-77)
• Motion (C-86)
• Moción (C-86-ES)
• Waiver of Appeal (C-108)
• Authorization to Receive Workers' Compensation Check (C-230)
• Autorización para recibir Cheques de compensación por accidentes en el trabajo (C-230-ES)
• Affidavit for Attorney Fees
• Application for Representative Identification Number (R-4)

Net present value factors chart 2015 - Effective Sept. 30, 2015

Resources
Compensation rates
Pension calendar
Absorption Rates for Overpayment Chart
Customer Service Office Triage Assignment and Contact Information
Exposure Blood or Other Bodily Fluid (ORC 4123.026) - flow chart

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