Form C-84 Bwc-1205 - Request For Temporary Total Compensation

Instructions for Completing the Request for

Temporary Total Compensation

This Request for Temporary Total Compensation (C-84) is the application you complete to request temporary total

disability benefits.

You must complete the entire form and sign it. It is your responsibility to secure supporting medical documentation from

your treating provider for the requested period of disability using the MEDCO-14 form or equivalent documentation.

You must complete this form every time you make a request for an initial period of temporary total compensation

or an extension of an existing period of temporary total compensation.

Instructions

Section

Injured worker demographics: BWC will use the address provided to mail all correspondence to you.

A home and/or cell phone number is helpful if we need to contact you. Providing your email address

allows you to communicate with your claims specialist electronically, if you choose to do so.

Section

Disability information: Please mark if this current period of disability is a new period of disability

or an extension. If this is an application for a new period of disability, please list the last day you

worked. For both new periods and requests for extensions of disability, list all providers currently

treating you for this claim.

Section

Employment information: BWC will use this information to help facilitate your return to work and

ensure proper payment.

Section

Vocational rehabilitation information: BWC will use this information to help facilitate your return

to work.

Section

Benefits/earnings received or requested during the period of disability: Indicate if you have received

any of the listed benefits. If you answer yes to any of the benefits on the list, provide the requested

information.

Section

Injured worker signature: Please sign and date this form when requesting temporary total disability

compensation. If you cannot sign, please mark the form and have a witness sign the form next to

your mark. Signing the form means you have answered the questions truthfully and completely.

It also means you are aware that you are not knowingly making a false statement, misrepresenta-

tion, concealment of fact or any other act of fraud to obtain compensation as provided by BWC or

knowingly accepting compensation to which you are not entitled. Providing false information or

concealing information to obtain compensation may subject you to felony criminal prosecution,

and may be punished by a fine, imprisonment, or both.

Where do I file the C-84?

For injured workers whose employer is self-insured: If your employer is self-insured, send the form to your employer.

If you are not sure if your employer is a self-insuring employer, contact your employer.

For all other injured workers: You may also complete this form online at . If you have completed a hard

copy of this form, fax it to 1-866-336-8352, or send it to the BWC customer service office where the claim is assigned.

Where do I find more information or assistance?

For injured workers whose employer is self-insured: Call your employer, or contact BWC’s self-insured department

at 1-800-OHIOBWC, and listen to the options to reach a BWC customer service representative.

For all other injured workers: Please call 1-800-OHIOBWC, or contact your BWC customer service office.

You can obtain BWC forms at , by calling 1-800-OHIOBWC and listening to the options to reach a

BWC customer service representative, or at your BWC customer service office.

C-84

BWC-1205 (Rev. 6/26/2012)

Form C-84 Bwc-1205 - Request For Temporary Total Compensation - 2012 Page 2

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