Forms + resources

form + function

Self-insured forms

Click the button to download the file for forms specific to self-insured claims. These forms can be used by clients, providers and injured workers.

First report of Injury (FROI) 

Injured workers, employers or medical providers use this form to initiate a workers' compensation claim. 

Physicians Report of Work Ability (Medco 14)

This form must be completed by a physician when placing the injured worker under work restrictions, requiring accommodations, or indicating he or she is temporarily totally disabled.

Change of Information (C-77)

Injured workers should use this form to notify the BWC of any changes in contact information.

Authorization to Release Medical Information (C-101)

Employers should make sure all their injured workers complete and sign this form to authorize the release of medical records so any medical providers can release information to BWC, the Industrial Commission, the employer, the managed care organization (MCO) or qualified health plan (QHP) and any authorized representatives.

Waiver of Appeal Period (C-108)

Injured workers, employers and/or their respective representatives should use this form to waive appeal rights on a BWC or IC order.

Waiver of Workers' Compensation Benefits for Recreational or Fitness Activities (C-159)

Employers should have all employees sign this form prior to engaging in sponsored recreational activities or fitness activities occurring on company property.

Request to Correct Employer and/or Policy Number Assignment (C-264)

Employers who need to correct employer or policy number assignments should complete this form.

Application to Add a Subsidiary to an Existing Self-Insured Account (SI-6S)

Complete this form if you're an employer adding a subsidiary to become self-insured with the parent company or individually.

Claims Liability Agreement (SI-16)

Complete this form if there is a third party's allegation that the insured is responsible for some loss or damage.

Unconditional and Continuing Guarantee (SI-38)

Complete this form to add a sub to an existing SI account.

Request for Taxpayer Identification Number and Certification (W-9) 

Employers and employees complete this form when there may be tax implications resulting from the claim.

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State-fund forms

Click the button to download the file for forms specific to our state-funded clients. 

First report of Injury (FROI) 

Injured workers, employers or medical providers use this form to initiate a workers' compensation claim.

Physicians Report of Work Ability (Medco 14)

This form must be completed by a physician when placing the injured worker under work restrictions, requiring accommodations, or indicating he or she is temporarily totally disabled.

Salary Continuation Agreement (C-55)

Complete this form if you're an employer offering salary continuation in lieu of temporary total compensation. 

Change of Information (C-77)

Injured workers should use this form to notify the BWC of any changes in contact information.

Authorization to Release Medical Information (C-101)

Employers should make sure all their injured workers complete and sign this form to authorize the release of medical records so any medical providers can release information to BWC, the Industrial Commission, the employer, the managed care organization (MCO) or qualified health plan (QHP) and any authorized representatives.

Waiver of Appeal Period (C-108)

Injured workers, employers and/or their respective representatives should use this form to waive appeal rights on a BWC or IC order.

Waiver of Workers' Compensation Benefits for Recreational or Fitness Activities (C-159)

Employers should have all employees sign this form prior to engaging in sponsored recreational activities or fitness activities occurring on company property.

State Fund Employer’s Agreement to Accept Claim Assignment (C-263)

State-fund employers complete this form when they are accepting assignment of a claim that BWC or another party mistakenly assigned to another state-fund employer.

Request to Correct Employer and/or Policy Number Assignment (C-264)

Employers who need to correct employer or policy number assignments should complete this form.

Request for Business Transfer Information (AC-4)

Complete this form if your employee was injured in the course of business travel. 

Request to Charge the Surplus Fund for Non-At-Fault Motor Vehicle Accident (AC-28)

Complete this form when your employee was injured as a result of a motor vehicle accident caused by an at-fault third party.

BWC Amended Payroll True-Up

Complete this form if you need to amend your previously submitted BWC True-Up report.

Employer/Employee Agreement to Select Ohio as the State of Exclusive Remedy for Workers' Compensation Claims (C-110)

Employers and their employees use this form to enter into a contract of employment outside of Ohio, when some or all of the work is to be performed outside of Ohio, and there is a possibility that the workers' compensation laws of both Ohio and another state could apply to the employment relationship. 

Application for Adjudication Hearing (Legal 15)

Use this form to request a hearing in front of the Committee on the employer's protest that the employer and appropriate BWC business unit have not resolved.

Settlement Application for Non-Complying Employee Claims (Legal 16)

Use this form to request a decision from the Adjudicating Committee to settle non-compliance liability claims with the state insurance fund.

Application for Ohio Workers' Compensation Coverage (U-3)

Use this form to establish workers' compensation coverage in Ohio. Ohio law requires any employer with one or more employees to carry workers' compensation coverage.

Request for Retroactive Coverage and Penalty Abatement or Waiver of Payroll True-Up Penalties (U-59)

Use this form to request retroactive coverage and penalty abatement for a lapse in coverage or a waiver of payroll true-up penalties.

Notification of Policy Updates (U-117)

Use this form to notify the BWC of changes to the legal business name and/or federal employer identification number or SSN for an existing policy.

Notification of Business Acquisition/Merger or Purchase/Sale (U-118)

Use this form to notify BWC that an acquisition or merger has occurred with an existing state fund policy.

Notice of Election to Obtain Coverage from Other States for Employees Working Outside of Ohio (U-131)

Ohio employers should complete this form when they have employees working temporarily in other states and have obtained the other states' coverage.

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Unemployment forms

Click the button to download the file for forms specific to our unemployment claims.

Employer's Representative Authorization for Benefits (JFS-00501) 

Use this form to authorize someone other than the employer to provide information pertaining to Unemployment Taxes.

Report to Determine Liability (JFS-20100)

The form is used to apply for an unemployment tax account. 

Transfer of Business (JFS-20101)

Submit this form to report the purchase of any portion of a trade or business.

Employer's Representative Authorization for Taxes (JFS-20106) 

The form gives a person or agency access to provide info about Unemployment Taxes.

Disposition of Business (JFS-20110)

The form is used to report a change of ownership or to close an account.

Application for Voluntary Successorship Transfer of Substantially All Assets (JFS-20118)

This is voluntary under the law. Under this type of transfer, the successor-in-interest assumes all of the resources and liabilities of the transferor's account, including the transferor's entire employment experience.

Application for Voluntary Successorship: Transfer of Clearly Segregable and Identifiable Portion (JFS-20119)

This is voluntary under the law. Under this type of transfer, the successor-in-interest assumes all of the resources and liabilities of the transferor's account, including the transferor's entire employment experience.

Request to Amend the Quarterly Tax Return (JFS-20129)

The form is used to amend an original quarterly tax return.

Waiver Request (JFS-20132)

The form is used to request a waiver of penalty and interest debts resulting from filing a late quarterly tax return.