Application For Wage Loss Compensation printable pdf download

Application for Wage Loss

Compensation

Instructions

 You must file this completed application when requesting an initial payment of wage loss compensation or for any requests for wage loss

compensation succeeding a broken period.

 You must also attach copies of current pay stubs, a payroll report with gross earnings or a completed Employer Report of Earnings for Wage Loss

Compensation (C-94A) when requesting working wage loss.

 You must also attach proof of job search using the Wage Loss Statement for Job Search (C-141) or equivalent form when requesting non-working

wage loss or working wage loss when job search is required.

 If BWC is processing your claim, fax the completed form to 1-866-336-8352, or send it to the BWC customer service office where your claim is

assigned.

 If a self-insuring employer is processing your claim, send this form directly to your employer.

Injured worker demographics: Complete this section in its entirety then proceed to section 2.

Injured worker name

Date of injury

Claim number

Address

City

State

Nine-digit ZIP code

Occupation or job title at time of injury

Email address

Contact number

Type of wage loss requested

I am requesting (Check all that apply and provide an end date if you are applying for a closed period).

Working wage loss benefits from ___________________ to ___________________. Complete and proceed to section 4.

Non-working wage loss benefits from ___________________ to _________________. Complete and proceed to section 3.

Registration with employment services (You must attach proof of registration) Complete and proceed to section 4.

I have registered with the Ohio Department of Jobs and Family Services or the applicable employment services agency in my residential state:

Yes

If you have registered in a state other than Ohio, which state? ___________________________________________________________________

Benefits received during the period of compensation requested: Complete this section in its entirety then proceed to section 5.

Type of benefit

Receiving

Beginning date of benefit

Wage replacement

Yes

Non-occupational and sickness benefits

Yes

Previous work history: Provide your complete employment history. Attach additional information to this form if necessary. Complete this section in its

entirety then proceed to section 6.

Name of employer

Dates of employment

Position description and list of job duties

Comments (please provide information regarding any other skills, education, or training not mentioned above):

Sought employment with the employer at the time of injury. Complete this section in its entirety then proceed to section 7.

Check one of the following:

I am presently employed by my employer at the time of my injury;

I have made application with my employer at the time of injury and I was unable to secure employment (proof of application must be attached to

this application);

My employer at the time of injury is out of business;

I have not applied with my employer at the time of injury because it would be futile. Please explain ____________________________________

_____________________________________________________________________________________________________________________

Medical documentation supporting restrictions Complete this section in its entirety then proceed to section 8.

Name of the physician who will be supplying medical documentation supporting restrictions due to the allowed conditions in my claim by

completing page two of this application: _________________________________ Phone number: ______________________________________

Job search Complete this section in its entirety then proceed to section 9.

I have not attached job search documentation (C-141 or equivalent form) to this application because:

I have returned to work with the employer at the time of injury;

I am only requesting wage loss for work days missed because of treatment that could not be obtained outside of work hours;

I am a work relief employee receiving public assistance;

Other (please explain) ________________________________________________________________________________________________

Injured worker’s signature

I have answered the foregoing questions truthfully and completely. I am aware that any person who knowingly makes a false statement,

misrepresentation, concealment of fact or any other act of fraud to obtain compensation as provided by BWC or self-insuring employers, or who

knowingly accepts compensation to which that person is not entitled is subject to felony criminal prosecution and may, under appropriate criminal

provisions, be punished by a fine or imprisonment or both. I hereby request payment of wage loss benefits for the period listed and certify that the

information listed on this Application for Wage Loss Compensation is correct to the best of my knowledge.

I have also given a copy of this application and any attachments to my employer at the time of injury unless the employer is out of business.

Injured worker signature

Date

BWC-1267 (Rev. May 13, 2014)

C-140

Application For Wage Loss Compensation

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