State of Ohio Workers’ Compensation Forms in Word

BWC # Form Title Price Buy Now
A-12 A.C.T. Enrollment and Direct Deposit Authorization $12.99
A-21 Electronic Benefit Card $12.99
A-35 Direct Deposit ACT Bank Change $12.99
C-5 Addition In Formation for Death Benefits $12.99
C-11 ADR Appeal to the MCO Medical Treatment/Service Decision $12.99
C-17 Request for Injured Worker Outpatient Medication Reimbursement $12.99
C-18 Wage Agreement $12.99
C-23 Notice to Change Physician of Record $12.99
C-30 Request for Medical In Formation $12.99
C-32 Application for Payment of Lump Sum Advancement $12.99
C-39 Annual Death Benefits Questionnaire $12.99
C-59 Self-Insurer’s Agreement as to Compensation on Account of Death $12.99
C-60 Completing the Injured Worker Statement for Reimbursement of Travel Expense $12.99
C-60-A Injured Worker Reimbursement Rates for Travel Expense $12.99
C-72 Authorization to Release In Formation $12.99
C-77 Injured Worker’s Change of Address Notification $12.99
C-84 Request for Temporary Total Compensation $12.99
C-84-ES Request for Temporary Total Compensation (En Español) $12.99
C-86 Motion $12.99
C-86-ES Motion (En Español) $12.99
C-92 Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability $12.99
C-94-A Wage Statement $12.99
C-101 Authorization to Release Medical In Formation $12.99
C-108 Waiver of Appeal $12.99
C-140 Initial Application for Wage Loss Compensation $12.99
C-141 Wage Loss Statement for Job Search $12.99
C-159 Waiver Of Workers’ Compensation Benefits For Recreational Or Fitness Activities $12.99
C-230 Authorization to Receive Workers’ Compensation Check $12.99
C-230-ES Authorization to Receive Workers’ Compensation Check (En Español) $12.99
C-240 Settlement Agreement and Application for Approval of Settlement Agreement $12.99
C-240-A Claimant’s Notice of Exception to Employer’s Signature Requirement $12.99
C-241 Amended Settlement Agreement and Release $12.99
C-255 Affidavit for Attorney Fees $12.99
FROI First Report of an Injury, Occupational Disease or Death $12.99
FROI-ES First Report of an Injury, Occupational Disease or Death (En Español) $12.99
Reporting fraud $12.99
IC-167-T Objection to Tentative Order Awarding Permanent Partial Disability Compensation $12.99
MEDCO-31 Request for Prior Authorization of Medication Form $12.99
OD-58-22 Application for Adjustment of Claim in Case of Death Due to Occupational Disease $12.99
R-2 Injured Worker Authorized Representative $12.99
RH-1 Rehabilitation Agreement $12.99
R-4 Application for Representative Identification Number $12.99
RH-6 On-the-job Training Agreement $12.99
RH-7 Loan/Release Agreement for Tool and Equipment $12.99
RH-10 Vocational Rehabilitation Plan Job Search Contacts $12.99
RH-18 Authorization for Living Maintenance Wage Loss $12.99
RH-24 Gradual Return to Work Agreement $12.99
SH-6 PERRP Complaint Form $12.99
SI-28 Filing of Allegation Against a Self-Insured Employer $12.99
SI-42 Self Insured Joint Settlement Agreement and Release $12.99
SI-43 Acknowledgement of the Self-Insured Joint Settlement Agreement and Release $12.99
Subrogation Referral Form $12.99