Self-Insuring Employer Notice and Request for Information for C-92/C-92A Application

Please fax the completed form and any other required information requested on this form within 14 days to 1- 866-336-8352. You do not have to return the C-92/C-92A application.

A complaint will be filed with BWC's self-insured department if you fail to provide this information.

The attached C-92/C-92A application was filed with the Ohio Bureau of Workers' Compensation (BWC). We are holding the application because we need the following from you:

Please verify the information that has been auto-populated to this form. If the information is incorrect, missing, or should be clarified, please make those corrections/clarifications on this form or attach corrections/clarifications to this form.

It is critical that you verify whether the allowed conditions listed below are correct, as these are the conditions that will be used to do an exam or file review for the requested percentage of permanent partial award. The conditions must include the ICD code(s), description(s), location (left/right/bilateral), if applicable and site (thumb, index/middle/ring fingers, etc.), if applicable.

Please forward, along with this completed form, any medical evidence relevant to this request for percentage of permanent partial impairment, that was not previously filed with BWC for this claim or any other claim, for the same or similar body part as listed in the injured worker claim demographic section below.

Injured worker claim demographic information – Please review and correct or clarify is necessary
Name	BWC claim number	Claim type
Address ,	Home phone number
Cell number
The following conditions are listed in the claim based on information that has been submitted to the BWC claim file.
Third Party Administrator (TPA) demographic information - Please review and correct or clarify is necessary
TPA name and ID number	TPA/Contact person
Mailing address
Toll-free phone number	Fax number
E-mail address
Physician of Record/Treating Physician(s) – Please complete the following
Physician of record for this claim	Effective date
All treating physicians for this claim
Compensation and Benefit payments – Please complete the following
Was temporary total (TT) and/or wage loss compensation was paid in this claim? Yes No If yes, list the type of compensation paid (TT or WL), provide the last period of disability for which temporary total (TT) and/or wage loss compensation was paid in this claim and include the date last payment was made (Example: TT paid for the period 5/21/05 to 7/30/06; last payment made 7/23/06) ______________________________ ___/___/___ to ___/___/___ ___/___/___ Type of payment Period of disability (begin and end date) Payment date ______________________________ ___/___/___ to ___/___/___ ___/___/___ Type of payment Period of disability (begin and end date) Payment date
Last date payment was made for medical services ___/___/___
List other types of compensation paid in this claim and last date of payment (Example: permanent partial, facial disfigurement, etc.; award paid date 2/1/03)
Additional Information Relevant to Processing This Request
Is the original or subsequent allowance under .512 appeal? ___ Yes ___ No
Have you entered into an agreement with the injured worker and completed an Agreement as to Compensation for Permanent Partial Disability (ICGC1) for any workers’ compensation claim? If yes, please attach copies of this agreement to your reply.