Ohio Bureau of Workers' Compensation
Electronic Signature
You have entered a part of our Web site that asks you to provide an electronic signature before we can process your request.
Providing information to BWC is your choice. Clicking "I agree" creates an electronic signature. An electronic signature is equivalent to your handwritten signature. Through the use of an electronic signature, you agree that the information you provide is accurate and complete to the best of your knowledge. You also acknowledge that you have read and understand the following warning statements. Please read these notices before providing us with your electronic signature: - About Information You Give Us
When you submit sensitive information over the Web site, that information is encrypted and protected by a secured socket layer (SSL).
- About Information You Receive
It is your responsibility to use the information provided to you on this Web site for its intended purposes.
- Fraud Warning
Any person or entity, who with purpose to defraud or knowing that a person is facilitating a fraud, obtains or attempts to obtain compensation or payment from BWC, an employer, or an MCO, by knowingly (1) misrepresenting or concealing a fact, (2) making a false statement, or (3) accepting compensation or payment to which he/she is not entitled, may be subject to repayment to BWC of all funds that have been overpaid, civil remedies, and/or felony criminal prosecution for fraud or other offenses. You are not entitled to Non-Statutory Permanent Total, Temporary Total, Non-Working Wage Loss, or Living Maintenance Disability benefits if you are working.
- Identity Fraud
Identity fraud perpetrated through the unauthorized use of BWC systems shall be prosecuted to the full extent of the law.
- Employer Fraud Warning
All employers in the state of Ohio are required to secure and maintain workers' compensation coverage with BWC or be granted self-insured status. Any person or entity who knowingly misrepresents the number or classification of employees or conceals a fact, makes a false statement, falsifies coverage, or makes any other attempt to avoid securing and maintaining coverage, or to avoid paying premiums or assessments in full, may be subject to repayment of funds due, administrative penalties, and/or criminal prosecution.
If you do not want to provide the requested information over this Web site, please click "I disagree" to receive further instructions.
If you are willing to provide the requested information over this Web site, please enter your initials in the box below and click "I agree" to continue.
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