Employer Report Of Employee Earnings - Ohio (Page 3 of 3) in pdf

Employer Report Of Employee Earnings - Ohio Page 3

Injured worker name

Claim number

Pay period

Gross regular

Other

Description of exceptions and earnings

end date

earnings

Comments or other information

I certify the information provided is correct to the best of my knowledge. I am aware that any person who knowingly makes a f alse statement,

misrepresentation, concealment of fact, or any other act of fraud to obtain payment as provided by the BWC or who knowingly accepts payment to

which that person is not entitled, is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine,

imprisonment or both.

I am requesting BWC calculate or recalculate the full and/or average weekly wage in this claim and adjust previously paid compensation pursuant to

RC 4123.52.

Name of the person completing this form (printed)

Date

Signature

Title

Fax the completed form to 1-866-336-8352, or send it to the BWC customer service office where the claim is assigned.

Wages-EMP

(Sept. 24, 2015)

Employer Report Of Employee Earnings - Ohio Page 3