Claims Kit
Ohio
Forms
Request for Temporary Total Compensation (Spanish)
Employer Report of Employee Earnings - formerly Wage Statement (C-94A)
Employer Report of Employee Earnings - formerly Wage Statement (C-94A) (Spanish)
First Report of an Injury, Occupational Disease or Death
Request for Temporary Total Compensation
First Report of an Injury, Occupational Disease or Death (Spanish)
State Compliance Information
Penalties for Late Reporting 4123.28
Each day that an employer fails to file a report constitutes an additional day within the time period given to a claimant for the filing of a claim based on the injury or occupational disease, provided that a failure to file a report will not extend the applicable statute of limitations for more than two additional years.
Posting Requirements RC 4123.83
Employers paying premiums into the state insurance fund or electing directly to pay compensation to the employer's injured employees or dependents must post the notice conspicuously in the employer's place of employment, which will be furnished at least annually by the bureau of workers' compensation . The notice must state that it is proof of workers' compensation coverage, or that the employer has complied with section 4123.35 of the Revised Code and has been authorized by the administrator of workers' compensation directly to compensate employees or dependents, and the date of the authorization. The notice must indicate that coverage is contingent on continued payment of premiums and assessments due. The notice constitutes sufficient notice to the employer's employees of the fact that the employer carries workers' compensation coverage or that the employer has complied with the elective provisions of section 4123.35 of the Revised Code
Physician Selection
If a worker is injured on the job, they can see any doctor for their first visit. But after the first doctor’s visit, the injured worker must select a BWC-certified medical provider as their Physician of Record (POR) to manage the treatment for a work-related injury.
If the initial doctor treating the injured worker is a BWC-certified medical provider, the worker can keep visiting that doctor. Or, the injured worker can select another BWC-certified medical provider.
Important: Except in an emergency or for the initial visit, the injured worker will be responsible for paying their medical bills if they have a non-BWC certified medical provider treat them.
Finding a BWC-certified provider
To locate a BWC-certified medical provider in your area:
View the BWC Provider Lookup;
Call BWC at 1-800-644-6292
Call the employer’s Managed Care Organization (MCO).
Although an injured worker's employer might also suggest a doctor for you to visit, the injured worker can visit any BWC-certified medical provider.
When any medical provider treats the work-related injury, give them the workers’ compensation claim number, the MCO information, and the conditions that are allowed in the claim.
Note: Doctors are also called the Physician of Record (POR) and the Treating Physician. A POR is a BWC-certified medical provider.
Changing a medical provider
The injured worker can change doctors by completing a (C-23) Notice to Change Physician of Record form. Then, send the completed form to their assigned Managed Care Organization (MCO) for processing.
If the employer is self-insured, complete the (C-23) Notice to Change Physician of Record form and send it directly to the injured worker's employer.
Reporting of Claim by Employer 4123.28 4123-3-03
Every employer will keep a record of all injuries and occupational diseases, fatal or otherwise, received or contracted by his employees in the course of their employment and resulting in seven days or more of total disability or death. Within a week after acquiring knowledge of an injury or death, or occupational disease, a report will be made in writing to the bureau of workers' compensation.
Posters & Brochures
Documents Provided by CopperPoint
Portal User Guides
Pharmacy First Fill
Pharmacy First Fill - Spanish
Change of Address
Witness Statement - English
Witness Statement - Spanish
Accident Report - English
Accident Report - Spanish
Gramm-Leach-Bliley Act (GLBA) Privacy Notice - English
Return To Work
Return To Work Transitional Employment Offer TemplateReturn To Work Transitional Employment Offer Template - Spanish
Return To Work Policy Guide
Injured Worker Guide
The worker's compensation system can be complicated, and each state has its own laws regarding workers' compensation.
The information contained in your state's guide provides a general guide for workers injured or made ill on the job.
This state-issued publication will assist you in navigating the workers' compensation system and serve as a resource for basic legal rights as well as steps to take to initiate workers' compensation benefits, deadlines and who to contact for additional assistance.
If you have questions about the workers' compensation process, this guide will provide the contact information for the regulatory agency for your state. In addition, many states have an ombudsman to oversee and assist all interested parties in the workers' compensation system.
Publications
Need help?
Phone: 800.231.1363
For Claim Reporting, please complete your First Notice of Loss and email to reportaclaim@copperpoint.com