OhioBWC - Worker - Form:  (ACT Enrollment and Direct Deposit)

ACT Enrollment and Direct Deposit Authorization (A-12)
Introduction
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Injured workers receiving disability benefits, excluding death and temporary partial are eligible for direct deposit and should use this form to apply for direct deposit of their workers' compensation payments. If you are currently receiving benefits through direct deposit, also known as electronic funds transfer, do not use this form. Instead, use the Direct Deposit ACT Change (A-35) to make any changes in your direct deposit. Automatic Comp Transfer (ACT) deposits your workers' compensation payments into a checking or savings account of your choice on the day payment is due.
Required information Bank routing number Bank account number Bank account type (checking or savings) Name on account
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BWC ACT P.O. Box 15429 Columbus, OH 43215-0429 Fax: (614) 752-8439
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