Providing information to BWC is your choice. When you update information on this Web site or use the electronic signature function, you agree that the information you provide is accurate and complete to the best of your knowledge.

If you are willing to provide the requested information over this Web site, enter your initials in the box and click to create an electronic signature.

If you do not want to provide the requested information over this Web site, click the button to return to the information verification page.

An electronic signature is similar to your handwritten signature. It also acknowledges that you have read and understand the following warning statements.

• About information you give us
  

  When you submit sensitive information over the Web site, that information is encrypted and protected by a secured socket layer (SSL). You can identify secured areas by the checkbox or icon displayed in the top right hand corner of the page.

• About information you receive
  

  It is your responsibility to use the information you receive from this Web site for its intended purposes and to protect any password(s) issued to you.

• Release of information
  

  Injured worker benefit application and medical release

  When you submit a First Report of Injury, Occupational Disease or Death (FROI), you are filing a claim for work-related injuries. An electronic signature from the injured worker, his or her authorized representative or delegate authorizes any medical provider who attends to, treats or examines the injured worker in regards to the related workers' compensation claim to release all medical, psychological, and/or psychiatric information to BWC, the Industrial Commission of Ohio, the employer listed in the claim, that employer's managed care organization (MCO), and any authorized representatives.

• Fraud warning
  

  Any person or entity, whose purpose is to defraud or who knows that a person is facilitating a fraud, obtains or attempts to obtain compensation or payment from BWC, an employer, or an MCO, by knowingly (1) misrepresenting or concealing a fact, (2) making a false statement, or (3) accepting compensation or payment to which he/she is not entitled, may be subject to repayment to BWC of all funds that have been overpaid, civil remedies, and/or felony criminal prosecution for fraud or other offenses. If you are working, you are not entitled to non-statutory permanent total, temporary total, non-working wage loss or living maintenance disability benefits.

• Employer fraud warning
  

  As an employer in the state of Ohio you are required to secure and maintain workers' compensation coverage with BWC or be granted self-insured status. Any person or entity who knowingly misrepresents the number or classification of employees or conceals a fact, makes a false statement, falsifies coverage, or makes any other attempt to avoid securing and maintaining coverage, or paying premiums or assessments in full, may be subject to repayment of funds due, administrative penalties, and/or criminal prosecution.