Ohio Workers' Compensation Information



Please Note: for Claims assistance or questions about coverage and exemptions You will need to call one of the numbers listed below.

Also be aware that the Workers' Compensation Assistance Offices in different states may go by different names such as "Industrial Accidents".
These are the only numbers that we are aware of and have available for Ohio Workers' Compensation.

Ohio Workers' Compensation Telephone Directory


Bureau of Workers' Compensation: 1-800-644-6292

Ombud's Office: 1-800-335-0996

Forms & Publications


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Some "Revision Dates" may be displayed as part of the Description.

(froi) First Report of an Injury, Occupational Disease or Death 8/20
(FROI-ES) First Report of an Injury, Occupational Disease or Death (Spanish) 6/14
(a-12) A.C.T. Enrollment and Direct Deposit Authorization 9/10
(a-12-ES) A.C.T. Enrollment and Direct Deposit Authorization (Spanish) 9/10
(a-21) Electronic Benefit Card 3/19
(a-21-ES) Electronic Benefit Card (Spanish) 3/19
(a-35) Direct Deposit ACT Bank Change 5/03
(a-35-ES) Direct Deposit ACT Bank Change (Spanish) 9/03
(c-5) Application for Death Benefits And/Or Funeral Expenses 5/19
(c-5-ES) Application for Death Benefits And/Or Funeral Expenses (Spanish) 3/16
(c-6) Application for Accrued Compensation 2/18
(c-11) ADR Appeal to the MCO Medical Treatment/Service Decision 9/09
(c-11-ES) ADR Appeal to the MCO Medical Treatment/Service Decision (Spanish) 4/09
(c-17) Request for Injured Worker Outpatient Medication Reimbursement 1/19
(c-18) Notice to BWC of the Injured Worker and Employer Agreement and Authorization to Send Injured Worker's Check(s) to the Employer 5/15
(c-23) Notice to Change Physician of Record 9/99
(c-30) Request for Medical Information 3/11
(c-32) Application for Payment of Lump Sum Advancement 2/18
(c-39) Annual Death Benefits Questionnaire 9/10
(c-59) Self-Insurer's Agreement as to Compensation on Account of Death 3/05
(c-60) Injured Worker Statement for Reimbursement of Travel Expense 11/14
(C-60-A) Injured Worker Reimbursement Rates for Travel Expense 4/20
(C-72) Consent to Release Information 8/12
(c-72-ES) Consent to Release Information (Spanish) 8/12
(c-77) Injured Worker's Change of Address Notification 2/18
(c-84) Request for Temporary Total Compensation 3/19
(c-84-ES) Request for Temporary Total Compensation (Spanish) 3/19
(c-86) Motion 9/20
(c-86-ES) Motion (Spanish) 9/20
(c-92) Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability 3/20
(c-92-ES) Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability(Spanish) 6/18
(Wages-IW) Injured Worker Earnings Statement 3/19
(Wages-IW-ES) Injured Worker Earnings Statement (Spanish) 3/19
(Wages-Emp) Employer Report of Employee Earnings - formerly Wage Statement (C-94A) 3/19
(Wages-Emp-ES) Employer Report of Employee Earnings - formerly Wage Statement (C-94A) (Spanish) 3/19
(C-101) Authorization to Release Medical Information 4/20
(C-101sp) C-101-ES Authorization to Release Medical Information (Spanish) 9/13
(C-108) Waiver of Appeal Period 4/12
(c-108-ES) Waiver of Appeal Period (Spanish) 4/12
(C-140) Initial Application for Wage Loss Compensation 5/14
(c-141) Wage Loss Statement for Job Search 3/09
(C-142) Employer Report of Employee Earnings for Wage Loss Compensation 3/19
(ic-167-t) Objection to Tentative Order 11/07
(C-159) Waiver of Workers' Compensation Benefits for Recreational or Fitness Activities 12/97
(c-159-ES) Waiver of Workers' Compensation Benefits for Recreational or Fitness Activities (Spanish) 12/97
(c-230) Authorization to Receive Workers' Compensation Check 6/14
(c-230-ES) Authorization to Receive Workers' Compensation Check (Spanish) 4/14
(C-240) Settlement Agreement and Application for Approval of Settlement Agreement 9/20
(C-240A) Claimants Notice of Exception to Employers Signature Requirement 1/07
(C-241A) Amended Settlement Agreement and Release 2/07
(c-255) Affidavit for Attorney Fees N/D
(C-262) Self-Insured Employer's Certification of Assignment After Initial Allowance N/D
(C-263) State Fund Employer's Agreement to Accept Claim Assignment N/D
(C-264) Request to Correct Employer and/or Policy Number Assignment N/D
(c-265) Presumption of Causation for Firefighter Cancer N/D
(MEDCO-31) Request for Prior Authorization of Medication 9/15
(PERRP) Summary of Work Related Injuries and Illness 1/20
(OD-58-22) Application for Adjustment of Claim in Case of Death Due to Occupational Disease 2/99
(r-2) Injured Worker Authorized Representative 12/19
(r-2-ES) Injured Worker Authorized Representative (Spanish) 10/16
(r-4) Application for Representative Identification Number (RIN) 7/16
(RH-1) Rehabilitation Agreement 3/16
(RH-6) On-the-Job Training Agreement 3/16
(RH-7) Loan/Release Agreement for Tools And Equipment 11/15
(rh-8) Vocational Rehabilitation Closure Report - Addendum 8/09
(RH-10) Injured Worker's Record of Job Search Contacts 12/08
(rh-13) Work Trial Agreement 3/16
(rh-14) Job Modification Agreement - Supplier Reimbursement 3/16
(rh-15) Job Modification Agreement - Return-to-Work (RTW) Employer 2/16
(RH-18) Authorization for Living Maintenance Wage Loss 2/20
(RH-24) Gradual Return to Work Agreement 11/15
(rh-42) Vocational Rehabilitation Initial Assessment Report 2/16
(rh-43) Vocational Rehabilitation Assessment Plan 5/16
(rh-44) Vocational Rehabilitation Comprehensive Plan 5/16
(rh-45) Authorization Request for Vocational Rehabilitation Plan 3/16
(rh-46) Vocational Rehabilitation Progress Report 5/16
(rh-47) Vocational Rehabilitation Job Retention Plan 5/16
(SH-12) Sharps Injury Form Needlestick Report 10/20
(SH-6) PERRP Complaint Form 10/20
(SH-27) Application for Workplace Wellness Grant Program 3/16
(SH-53) Application for Safety Intervention Grant 10/20
(SI-28) Filing of an Allegation Against a Self-Insured Employer 1/20
(SI-42) Self Insured Joint Settlement Agreement and Release 1/05
(SI-43) Acknowledgment of the Self-Insured Joint Settlement Agreement and Release Instructions 10/97
(SubroRefer) BWC Subrogation Referral Form N/D
(ac-18) Labor Lease Transaction Payroll 1/12
(ac-19) Labor Lease Transaction Claims 12/10
(ac-2) Permanent Authorization 11/18
(ac-2-ES) Permanent Authorization (Spanish) 5/18
(ac-3) Temporary Authorization to Review Information 2/15
(ac-3-ES) Temporary Authorization to Review Information (Spanish) 10/12
(ac-4) Request for Business Transfer Information 7/15
(C-9-A) Request for Additional Medical Documentation for C-9 3/11
(C-9-APsych) Request for Additional Medical Documentation for C-9 Psychological Services 11/16
(C-55) Salary Continuation Agreement 6/08
(C-110) Agreement to Select the State of Ohio as the State of Exclusive Remedy 4/09
(C-112) Agreement to Select a State Other than Ohio as the State of Exclusive Remedy 4/09
(C-174) Self-Insured Semiannual Report of Claim Payments 8/09
(C-261) Workers' Compensation Claim Log N/D
(CHP-4A) Application for Handicap Reimbursement 4/09
(DFSP-1) Accident Report N/D
(DFSP-3Sample) DFSP-3 Drug-Free Safety Program (DFSP) Annual Report – Basic and Advanced Levels (sample) 10/14
(DFSP-4Sample) DFSP-4 Drug-Free Safety Program (DFSP) Annual Report - Comparable Program Only (sample) 10/14
(DFSP-5) DFSP-5 DFSP Safety Action Plan 10/14
(LEGAL-16) Settlement Application for Non-complying Employer Claims 4/02
(MEDCO-6) Waiver of Examination 2/19
(MEDCO-8) Self Insured Employer/Injured Worker Screening 2/99
(OCP-1) Application for One Claim Program 9/14
(R-1) Employer Authorized Representative 12/19
(RH-5) Trainers Report 10/15
(RH-19) Employer Incentive Contract 10/15
(RH-94A) Report of Earnings for Living Maintenance Wage Loss Compensation 2/16
(PayrollAmend) Amended True Up Payroll Report 10/16
(SA-5) PDP Self-Assessment 12/09
(SI-6) Initial Application by Employer for Authority to Pay Compensation Etc. Directly 10/19
(si-6s) Application to Add a Subsidiary to an Existing Self-Insured Policy N/D
(SI-7) Application for Renewal of Authorization to Operate as a Self-Insured Risk 2/13
(SI-16) Agreement Between Employer and the Ohio BWC Regarding Amount of Self-Insured Buyout 12/08
(SI-38) Unconditional and Continuing Guarantee 3/03
(SI-40) Report of Paid Compensation and Statistical Information 10/19
(SI-44) Election to Withdraw from Claims Reimbursement Fund 6/06
(SI-51) Application for Certification of Qualified Health Plan (QHP N/D
(TWB-1) Application for Transitional Work Bonus Program 10/14
(TWB-2) Transitional Work Offer and Acceptance Form 12/19
(TWB-2ES) Transitional Work Offer and Acceptance Form (Spanish) 1/16
(TWG-1) Application for Transitional Work Grant Program 8/16
(TWG-2) Transitional Work Grant Reimbursement Request Form 5/17
(TWG-3) Transitional Work Grant Agreement 5/17
(twd-115) Transitional Work Developer's Application 5/17
(UA-3SI-1) Self-Insured Professional Employer Organization (PEO) Client Relationship Notification 5/19
(U3) Application for Ohio Workers" Compensation Coverage 5/17
(U3-ES) Application for Ohio Workers" Compensation Coverage (Spanish) 10/15
(U-3E) Application for Exemption from Ohio Workers' Coverage and Waiver of Benefits 8/19
(U-3S) Application for Elective Coverage 4/19
(U-3S-ES) Application for Elective Coverage (Spanish) 10/06
(UA-3) Professional Employer Organization Client Relationship Notification 3/19
(UA-6) 10-Step Business Plan Plan of Action (POA) 12/09
(U-108) Opt Out of .99 EM Construction Cap Program 9/15
(U-19) Public Employer Agreement for 100-percent EM Cap 12/11
(U-20) Application for Retrospective Rating Plan For Private Employers 4/16
(U-21) Application for Retrospective Rating Plan for Public Employers 4/16
(U-59-1) Request for Retroactive Coverage and Penalty Abatement or Waiver of Payroll True-Up Penalties 4/20
(u80) Apprenticeship Elective Coverage Contract 9/17
(U-117) Notification of Policy Update 8/16
(U-118) Notification of Business Acquisition/Merger or Purchase/Sale 10/10
(U-131) Notice of Election to Obtain Coverage from Other States for Employees Working Outside of Ohio N/D
(U-140) Application for Drug-Free Workplace Program and Drug-Free EZ 10/14
(U-145) Lump Sum Settlement (LSS) 3/14
(U-147) Non-Ohio Amended Payroll Report 10/11
(U-148) Application for Deductible Program 10/14
(U-149) Sponsor Certification Application 4/16
(U-159) Other States Coverage – Trucking Supplemental Application 7/16
(PayrollExtPayPlan) Extended Payment Plan N/D
Fax Cover Sheet 3/09
(c-9) Physicians Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease 12/11
(C-19) Service Invoice 9/10
(C-143) DEP Physician's Report of Work Ability 5/16
(C-143PC) Disability Evaluator Panel (DEP) Physician's Report of Work Ability Cognitive/Psychological Conditions 8/16
(C-190) Justification of Necessity for Seating/Wheeled Mobility 11/97
(C-196) Amputation/Loss of Use Diagram 4/17
(MEDCO-12) Request to Change Provider Information 1/20
(MEDCO-13) Provider Enrollment and Certification 8/20
(MEDCO-13a) Provider Enrollment Application (certification not required) 8/20
(MEDCO-14) Physician's Report of Work Ability 8/15
(MEDCO-30) Disability Evaluator Application 3/11
(RH-2) Individualized Vocational Rehabilitation Plan 8/09
(RH-21) Vocational Rehabilitation Closure Report 8/09
(ecptx) Physicians Treatment Request ECP-TX N/D
(LEGAL-15) Application for Adjudication Hearing 7/08
(MEDCO-32) Request for Prior Authorization of Non-Preferred Medication 9/09
(ic8-9) Application for Additional Award for Violation of Specific Safety Requirement in a Workers' Compensation Claim 5/19
(ic2) Application For Compensation For Permanent Total Disability 9/15
(ic12) Notice Of Appeal 2/17
(U-18) Private Employer Agreement for 100-percent EM Cap 4/11
(U-142) Drug-Free Self-Assessment Progress Report 10/08
(MEDCO-16) Mental Health Notes Summary 7/10
(MEDCO-22) Medication Physician Review 1/15
(MEDCO-34) MCO Request for Drug Utilization Review 4/17
(MEDCO-35) Formulary Medication Request Form 10/12
(MEDCO-38) Certification Agreement Between the Injured Worker and Service Provider ( Contractor ) N/D
(AC-28) Request to Charge the Surplus Fund forNon-At-Fault Motor Vehicle Accident 12/19
(U-158) Pre-audit Questionnaire 2/19
(U-158-ES) Pre-audit Questionnaire (Spanish) 2/19
(C-512) Notice Of Intent To Settle ( C-512 ) 6/18

Chapter 4121: Industrial Commission

Chapter 4123: Bureau of Workers' Compensation

Chapter 4125: Industrial Commission/Worker's Compensation

Chapter 4121: Industrial Commission; Bureau of Workers' Compensation (4121.01 - 4121.99)

Chapter 4123: Workers' Compensation (4123.01 - 4123.932)