OhioBWC - Worker:  PPS - Elective Coverage Introduction

INTRODUCTION TO APPLICATION FOR WAGE LOSE COMPENSATTION (C-140)

Run Scenario The injured worker uses this form to apply for wage loss compensation. The injured worker and the physician of record must complete this form. The injured worker supplies information regarding current work status and employment history. The physician supplies information regarding the injured worker’s work restrictions and physical capacity. The C-140 may be completed online, however it must be printed off for mail or fax submission. Required Information: When the C-140 is completed online, the injured worker’s name, address, telephone number, date of birth, social security number, claim number, occupation at the time of injury, and the injury employer’s name, address and telephone number will be automatically populated on the form.The injured worker will need to verify that this information is correct. Injured worker information can changed online by selecting the link to claim demographics, however employer information changes cannot be made online.Contact BWC at 1-800-OHIOBWC if employer information is incorrect. The following additional information is required from the injured worker: Dates and type of wage loss being applied for; Work history information including employer names, dates of employment, job titles, and reasons for leaving and earnings. The following additional information is required from the physician: Physician information including:name, address and telephone number. Injured worker information including: date of last medical examination, restrictions (permanent and/or temporary) as a result of the allowed conditions in the claim, duration of temporary restrictions (if applicable), and any other restrictions (not related to claim). Injured worker physical capacity for sitting, standing, walking, bending, squatting, crawling, climbing, reaching, lifting, carrying; use of hands in repetitive actions, such as grasping, pushing and pulling arm controls, and fine manipulation; and use of feet in repetitive movements of leg controls. Run Scenario