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-------BWC forms for Employers------- AC-2 Permanent Authorization AC-3 Temporary Authorization to Review Information C-59 Self-Insurer's Agreement as to Compensation on Account of Death C-86 Motion C-108 Request for Waiver of Appeal C-110 Agreement - For Employers Based out of State and with Employees in Ohio C-112 Agreement - For Employers Based in the State and Employees out of Ohio C-167-T Objection to Tentative Order Awarding Permanent Partial Disability Compensation C-174 Self-Insured Semi-Annual Report of Claim Payments C-240 Settlement Agreement and/or Appl. for Approval of Settlement Agreement C-241 Amended Settlement Agreement and Release CHP-4-A Application for Handicapped Reimbursement FROI-1 First Report of an Injury, Occupational Disease or Death MEDCO-6 Wavier of Examination MEDCO-8 Self-Insured Employer/Claimant Screening R-1 Authorization of Representative of Employer R-3 Request to Inspect Claim and Risk File RH-19 Employer Incentive Contract RH-5 Trainer's Report RH-24 Gradual Return-to-Work Contract Reimbursement Method SI-42 Self-Insured Joint Settlement Agreement and Release SI-43 Acknowledgment of the Self-Insured Joint Settlement Agreement and Release U-3 Application for Coverage U-3S Application for Elective Coverage U-9 Application for Transfer of Workers' Compensation Account and Premium Obligation UA-5 Application for Premium Discount Program

-------BWC forms for Ohio's Workforce------- C-5 Additional Information for Death Benefits C-23 Change of Doctor Request C-58 Application for Adjustment of Claim in Case of Fatal Injury C-60 Claimant Travel Expense C-77 Injured Worker's Change of Address C-84 Request for Temporary Total Compensation C-86 Motion C-92 Application for Determination of the Percentage of Permanent Partial Disability C-92-A Application for Increase of the Percentage of Permanent Partial Disability C-94-A Wage Statement C-101 Authorization to Release Medical Information C-108 Request for Waiver of Appeal C-140 Application for Wage Loss Compensation C-141 Wage Loss State for Job Search C-159 Waiver of Workers' Comp Benefits to Recreational or Fitness Activities C-181 Fee Bill Inquiry C-230 Authorization to Receive Workers' Compensation Check C-240 Settlement Agreement and/or appl. for Approval of Settlement Agreement C-241 Amended Settlement Agreement and Release FROI-1 First Report of an Injury, Occupational Disease or Death OD-58-22 Application for Adjustment of Claims in Case of Death on Account of Occupational Disease R-2 Authorization of Representative of Claimant R-3 Request to Inspect Claim and Risk File RH-18 Six Month Authorization to Pay Rehab Wage Loss Payments RH-18A Living Maintenance Wage Loss Re-Employment Agreement RH-19 Employer Incentive Contract RH-24 Gradual Return-to-Work Contract Reimbursement Method SI-28 Filing of Complaint Against Self-Insured Employer SI-42 Self-Insured Joint Settlement Agreement and Release SI-43 Acknowledgment of the Self-Insured Joint Settlement Agreement and Release

-------BWC forms for the Medical Community------- C-9 Physician's Report/Treatment Plan for Industrial Injury or Occupational Disease C-17 Pharmacy Invoice C-17 Pharmacy Invoice (Continuous Pin Feed -2,500 per box) C-19 Service Invoice C-19 Service Invoice (Continuous Pin Feed -2,500 per box) C-44 Physician's Certificate in Proof of Death C-84 Request for Temporary Total Compensation C-151 Status Response C-181 Fee Bill Inquiry C-190 Justification of Medical Necessity for Seating/Wheeled Mobility RH-1 Rehabilitation Agreement RH-2 Individualized Rehabilitation Plan RH-5 Trainer's Report RH-6 On-The-Job Training Agreement RH-7 Loan/Release Agreement for Tools and Equipment RH-18 Six Month Authorization to Pay Rehabilitation Wage Loss Payments RH-18A Living Maintenance Wage Loss Re-Employment Agreement RH-19 Employer Incentive Contract RH-21 Vocational Rehabilitation Closure Report RH-24 Gradual Return to Work Contract Reimbursement Method RH-27 Prescription for Work Hardening

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