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Home
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Workers' Compensation State Laws and Regulations >
Ohio Workers' Comp Laws and Regulations
Ohio Workers' Compensation Forms
Ohio
Workers' Compensation
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Ohio Workers' Compensation Rules
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Ohio Workers' Compensation Statutes
Chapter 4121: Industrial Commission |
Ohio Workers' Compensation Forms
(All links open in new window.)
Each form may be downloaded in Adobe Acrobat format. Download the form by clicking on the form number below and follow the specific instructions for that form, which are included. Please note that some forms are used in pairs. If you do not have Adobe Acrobat Reader, you may download it here for free.. Download Adobe Here (opens in new window)
| File Name | Description |
|---|---|
| froi.pdf | First Report of an Injury, Occupational Disease or Death - 2/08 |
| FROI-ES.pdf | Primer informe de una lesión (FROI, por sus siglas en inglés), enfermedad de trabajo o muerte - 8/05 |
| a-12.pdf | A.C.T. Enrollment and Direct Deposit Authorization - 1/08 |
| a-21.pdf | Electronic Benefit Card - N/D |
| a-35.pdf | Direct Deposit ACT Bank Change - 5/03 |
| ac-2.pdf | Permanent Authorization - 7/05 |
| ac-3.pdf | Temporary Authorization To Review Information - 6/05 |
| ac-3-ES.pdf | Autorización Provisional Para Revisar La Información - 6/05 |
| ac-18.pdf | Labor Lease Transaction Payroll - 10/04 |
| ac-19.pdf | Labor Lease Transaction Claims - 10/04 |
| bwc-7500.pdf | Plan of Action - 5/03 |
| c-5.pdf | Addition Information for Death Benefits - 9/05 |
| C-9.pdf | Physicians Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease - 2/08 |
| C-9-A.pdf | Request for Additional Medical Documentation for C-9 - 10/04 |
| c-11.pdf | ADR Appeal to the MCO Medical Treatment/Service Decision - 2/02 |
| c-17.pdf | Outpatient Medication Invoice - 2/08 |
| c-18.pdf | Wage Agreement - 6/01 |
| C-19.pdf | Service Invoice - 4/04 |
| c-23.pdf | Notice to Change Physician of Record - 9/99 |
| c-30.pdf | Request for Medical Information - 10/04 |
| c-32.pdf | Application for Payment of Lump Sum Advancement - 11/04 |
| c-39.pdf | Annual Death Benefits Questionnaire - 4/05 |
| C-44.pdf | Physicians Certificate in Proof of Death - 8/01 |
| C-55.pdf | Salary Continuation Agreement - 6/05 |
| c-59.pdf | Self-Insurer's Agreement as to Compensation on Account of Death - 3/05 |
| c-60.pdf | Injured Worker Statement for Reimbursement of Travel Expense - 7/06 |
| c-60a.pdf | Injured Worker Reimbursement Rates for Travel Expense - 6/07 |
| c-77.pdf | Injured Worker's Change of Address Notification - 7/03 |
| c-84.pdf | Request for Temporary Total Compensation - 5/07 |
| c-84-ES.pdf | Solicitud De Compensación Total Temporal - 4/04 |
| c-86.pdf | Motion - 9/07 |
| c-92.pdf | Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability - 12/01 |
| C-94a.pdf | Wage Statement - 1/04 |
| C-101.pdf | Authorization to Release Medical Information - 3/03 |
| C-108.pdf | Waiver of Appeal Period - 3/02 |
| C-110.pdf | Agreement to Select the State of Ohio as the State of Exclusive Remedy - 9/07 |
| C-112.pdf | Agreement to Select a State Other than Ohio as the State of Exclusive Remedy - 9/07 |
| C-140.pdf | Initial Application for Wage Loss Compensation - 6/06 |
| c-141.pdf | Wage Loss Statement For Job Search - 6/06 |
| C-143.pdf | DEP Physician's Report of Work Ability - 6/04 |
| C-159.pdf | Waiver of Workers Compensation Benefits for Recreational or Fitness Activities - 12/97 |
| C-190.pdf | Justification of Necessity for Seating/Wheeled Mobility - 11/97 |
| C-196.pdf | Amputation/Loss of Use Diagram - 10/04 |
| c-230.pdf | Authorization to Receive Workers' Compensation Check - 11/03 |
| c-230-ES.pdf | Autorización para recibir cheque del seguro de compensación por accidentes en el trabajo - 11/03 |
| C-240.pdf | Settlement Agreement and Application for Approval of Settlement Agreement - 2/07 |
| C-240A.pdf | Claimants Notice of Exception to Employers Signature Requirement - 1/07 |
| C-241A.pdf | Amended Settlement Agreement and Release - 2/07 |
| c-255.pdf | Autorización para recibir cheque del seguro de compensación por accidentes en el trabajo - N/D |
| CHP-4A.pdf | Application for Handicap Reimbursement - 12/01 |
| Fax.pdf | Fax Cover Sheet - 11/00 |
| ic-167-t.pdf | Objection to Tentative Order - 4/07 |
| LEGAL-15.pdf | Employer Adjudication Protest - 4/02 |
| LEGAL-16.pdf | Settlement Application for Non-complying Employer Claims - 4/02 |
| MEDCO-6.pdf | Waiver of Examination - 2/99 |
| MEDCO-8.pdf | Self Insured Employer/Injured Worker Screening - 2/99 |
| MEDCO-12.pdf | Request to Change Provider Information - 1/08 |
| MEDCO-13.pdf | Provider Enrollment and Certification - 9/07 |
| MEDCO-13a.pdf | Provider Enrollment-Non Certification - 9/07 |
| MEDCO-14.pdf | Physician's Report of Work Ability - 4/02 |
| MEDCO-31.pdf | Request For Prior Authorization Of Medication - 5/05 |
| MEDCO-32.pdf | Request For Prior Authorization Of Non-Preferred Medication - 5/05 |
| OD-58-22.pdf | Application for Adjustment of Claim in Case of Death Due to Occupational Disease - 2/99 |
| OneClaim.pdf | Application for One Claim Program - 2/05 |
| PayrollAmend.pdf | Amended Payroll Report - 6/03 |
|
PayrollExtPay Plan.pdf |
Extended payment plan - N/D |
|
PERRP Complaint.pdf |
PERRP Complaint Form - N/D |
|
ProviderFee Schedule.pdf |
2007 Provider Fee Schedule |
| R-1.pdf | Employer Authorized Representative - 5/06 |
| r-2.pdf | Injured Worker Authorized Representative - 5/06 |
| RH-1.pdf | Rehabilitation Agreement - 1/99 |
| RH-2.pdf | Individualized Vocational Rehabilitation Plan - 3/99 |
| RH-5.pdf | Trainers Report - 3/99 |
| RH-6.pdf | On-the-Job Training Agreement - 3/99 |
| RH-7.pdf | Loan/Release Agreement For Tools And Equipment - 10/03 |
| RH-10.pdf | Injured Worker's Record Of Job Search Contacts - 11/01 |
| RH-19.pdf | Employer Incentive Contract - 3/99 |
| RH-21.pdf | Vocational Rehabilitation Closure Report - 11/01 |
| RH-24.pdf | Gradual Return to Work Agreement - 11/01 |
| SA-5.pdf | PDP+ Self-Assessment - N/D |
| SI-6.pdf | Initial Application by Employer for Authority to Pay Compensation Etc. Directly - 3/89 |
| SI-7.pdf | Application for Renewal of Authorization to Operate as a Self-Insured Risk - 8/97 |
| SI-16.pdf | Agreement Between Employer and the Ohio Bureau of Workers Compensation Regarding Amount of Self-Insured Buyout - 8/99 |
| SI-28.pdf | Filing of an Allegation Against a Self-Insured Employer - 2/04 |
| SI-38.pdf | Unconditional and Continuing Guarantee - 3/03 |
| SI-40.pdf | Report of Paid Compensation and Statistical Information - 10/00 |
| SI-41.pdf | Handicap Reimbursement Program Withdrawal Form - 9/99 |
| SI-42.pdf | Self Insured Joint Settlement Agreement and Release - 1/05 |
| SI-43.pdf | Acknowledgment of the Self-Insured Joint Settlement Agreement and Release Instructions - 10/97 |
| SI-44.pdf | Election to Withdraw from Claims Reimbursement Fund - 6/06 |
| SubroRefer.pdf | BWC Subrogation Referral Form - N/D |
| U3.pdf | Application for Ohio Workers Compensation Coverage - 4/07 |
| U-3E.pdf | Application for Exemption from Ohio Workers' Coverage and Waiver of Benefits - 11/07 |
| U-3S.pdf | Application for Elective Coverage - 10/06 |
| U-20.pdf | Application for Retrospective Rating Plan For Private Employers - 3/07 |
| U-21.pdf | Application for Retrospective Rating Plan For Public Employers - 3/07 |
| U-117.pdf | Notification of Policy Update - 11/06 |
| U-140.pdf | Application for Drug-Free Workplace Program and Drug-Free EZ - 1/08 |
| U-142.pdf | Drug-Free Self-Assessment Progress Report - 10/07 |
| U-145.pdf | Lump Sum Settlement (LSS) - 10/05 |
| UA-3.pdf | Professional Employer Organization Client Relationship Notification - 7/04 |
| UA-5.pdf | Application for the Premium Discount Program - 1/08 |
For more information about how you can greatly reduce your Workers' Compensation costs,
call us at 860-786-8286, or send us an e-mail, or
simply submit this short form.