Injured workers use this form to notify BWC that they've authorized a representative to act on their behalf in all BWC matters. Then, the authorized representative can act as the injured worker's agent, reviewing files, filing paperwork and interacting with BWC personnel.

To dismiss an authorized representative, BWC must receive written and signed notification from the injured worker. According to Ohio Administrative Code 4123-3-22(C), the injured worker may submit a notice BWC or a new R-2 for another representative.

When a claims service specialist receives a request for dismissal of an authorized representative, he or she will notify the injured worker to submit a separate written dimissal for an authorized rep receiving workers' compensation checks i.e., power of attorney. The injured worker must also send a written dismissal to the representative(s).

• Representative's name, mailing address, including city, state, and ZIP code
• The representative's phone number

If you have all the required information on hand, simply click the start button to begin.