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Ohio
Workers' Compensation Guide:
Forms
Although much information is being gathered
electronically, the Ohio Workers' Compensation system still depends on
forms to gather information. Below is a listing of some common forms,
and a description of what the forms are used for.
A number of these forms can be viewed or printed from
the Bureau of Workers' Compensation's forms
page or the Industrial Commission's forms page.
Some of them can be filled out and filed on-line.
Tips:
- Always put your claim number in the upper right hand
corner of every page of the form (or any
other document you file), before filing it.
- Have an extra copy of the form time-stamped and keep
the copy for your records. That way, if the form is lost, you have
proof that the form was filed.
- If you want to highlight information, circle it or
draw an arrow. Don't use a highlighter, because it may make the
information appear as a black line when the document is scanned.
Forms:
- FROI-1 -- "First report of an injury, occupational
disease, or death" form. It is the basic form which is used to file a
workers' compensation claim. [To view or print this form from the
Bureau of Workers' Compensation's web site, click
here.]
- C-84 -- Application for Temporary
Total Compensation, must be filled out by the injured worker and
the doctor. [To view or print this form from the Bureau of Workers'
Compensation's web site, click
here.]
- C-86 -- This is the form for filing "motions", which
are requests for actions which are not covered by other forms. [To view
or print this form from the Bureau of Workers' Compensation's web site,
click
here.]
- C-92 -- Application for Permanent
Partial Compensation, or increases in the Permanent Partial award.
[To view or print this form from the Bureau of Workers' Compensation's
web site, click
here.]
- C-94A -- Wage statement, used to report earnings for
year before injury, so that the average
weekly wage can be calculated.[To view or print this form from the
Bureau of Workers' Compensation's web site, click
here.]
- IC-2 -- Application for Permanent
Total Compensation . [To view or print this form from the
Industrial Commission's web site, click here.]
- IC-8/9 -- Application for an award for the Violation of a Specific Safety Requirement.
[To view or print this form from the Industrial Commission's web site, click here.]
- IC-12 -- Notice of
Appeal. [To view or print this form from the Industrial
Commission's web site, click here.]
- SI-28 -- Complaint against Self-Insured Employer. [To
view or print this form from the Bureau of Workers' Compensation's web
site, click
here.]
Other information:
JaffyLaw.com:
Other Web Sites:
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Workers' Compensation Guide
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