OhioBWC - Worker:  Step by Step Instructions for Completion of C240

Step-by-Step Instructions for Completing the Settlement Agreement and Application for Approval of Settlement Agreement (C-240)

IMPORTANT - Complete all sections of this form with as much information as possible.

Section One – Injured Worker Information

Injured worker name - enter first, last and middle initial if applicable. Social Security number - enter you SSN. Date of birth - enter the month, day and year of birth. Street Address - enter your home address. Include apartment number if applicable. City - enter city where you live. State - enter state where you live. ZIP Code - enter your nine-digit ZIP code. If nine-digit ZIP code is unknown, enter five-digit ZIP code. Phone number - enter your area code and home phone number.

Section Two – Injured Worker Representative Information

Injured worker representative's name - enter injured worker representative's name. ID number - enter your representative's identification number. Street Address - enter your representative's business address. City - enter city of your representative. State - enter state of your representative. ZIP Code - enter nine-digit ZIP code for your representative. If you don't know the nine-digit ZIP code, enter five-digit ZIP code. Phone Number - enter area code and phone number for your representative.

Section Three – Employer Information

Employer name - enter the name of the employer of record. If more than one employer is involved, you must file separate applications for each employer. Policy Number - enter your employer policy number. Street Address - enter employer's address. City - enter city where employer of record is located. State - enter state where employer of record is located. ZIP Code - enter nine-digit ZIP code of employer if possible. If you don't know the nine-digit ZIP code, enter five-digit ZIP code. Fax Number - enter area code and fax number for your employer. Phone Number - enter area code and phone number for your employer.

Section Four – Employer Representative’s Information

Employer Representative's Name - enter the name of the representative for the employer of record in the claim. ID Number - enter employer of record representative's ID number. Street Address - enter address of the employer of record's representative. City - enter city of the employer of record's representative. State - enter state where employer of record's representative is located. ZIP Code - enter nine-digit ZIP code of employer representative if possible. If you don't know the nine-digit ZIP code, enter five-digit ZIP code. Fax Number - enter fax number for the employer of record's representative. Phone Number - enter phone number for the employer of record's representative.

Section Five – Other Relevant Employers

Have you attached information on other relevant employers? Check box indicating yes or no.

Section Six - Claim(s) to be Included in Settlement

Claim Number - enter claim number(s) to be included in settlement. Requested Amount for Complete Settlement - enter the amount of money that you want to settle the claim(s) specified. Proposed Allocation of Requested Settlement Amount (Indemnity) - enter the amount of money that you want to settle the compensation portion of the claim(s) specified. Proposed Allocation of Requested Settlement Amount (Prescription Drugs) - enter the amount of money that you want to settle the prescription drugs portion of the claim(s) specified. Proposed Allocation of Requested Settlement Amount (Medical) - enter the amount of money that you want to settle the medical portion of the claim(s) specified. List any claims specifically excluded from settlement - enter the claim(s) that you do not wish to settle at this time. Please explain any request for a "partial" settlement - enter information explaining why you do not wish to settle all parts of claim(s) that are listed.

Circumstances of which the settlement is deemed desirable

Clearly set for the circumstance by reason of which the proposed settlement is deemed desirable - list the reason why you want to settle the claim, anticipated medical costs, future compensation, etc. (This field is optional.) Have you attached information on other relevant claims? Check box indicating yes or no. (This field is optional.) Are you receiving, or have you applied for Medicare benefits? Check box indicating yes or no. (This field is optional.) Are you receiving medical treatment at this time? Check box indicating yes or no. (This field is optional.) Who is your treating physician(s)? List the name of your current treating physician and any other doctors treating you. (This field is optional.) Wages at the time of injury - indicate earnings at the time of injury. (This field is optional.) Are you working? Check box indicating yes or no. (This field is optional.) If yes, who is your employer? Enter the name of your employer. (This field is only required if you are working.) What is your current occupation? Enter your current job. (This field is only required if you are working.) What are your current wages? Enter your current earnings. (This field is required only if you are working.)

Section Seven - Settlement Signatures, Agreement and Release

Please check one of the following boxes and sign below. Your signature does not waive the employer's right to withdraw consent to the settlement by providing written notice to the employee and BWC administrator within 30 days after the administrator issues the approval of the settlement agreement - check box indicating A, B, C or D. (Completion of this section is mandatory. The settlement will not be processed without it.) Employer signature - employer or employer's representative must sign here. (Completion of this section is mandatory.) Title - enter the title of the person signing off on the settlement. (Completion of this section is mandatory.) Date - enter the date the employer signs the settlement application. (Completion of this section is mandatory.) Phone Number - enter area code and phone number of employer. Fax Number - enter area code and fax number for your employer.

Section Eight - Settlement Agreement and Release

Injured Worker Signature - you must sign here. (Completion of this section is mandatory.) Date - enter the date you sign the settlement application. (Completion of this section is mandatory.)

Section Nine – Power of Attorney

Injured Worker Signature - If you sign here, you grant a limited power of attorney to the authorized representative. This authorizes him or her to receive the settlement check once BWC releases it. Date - enter date power of attorney is authorized. Representative signature - This authorizes the representative to receive the settlement check once BWC releases it. Date - enter date authorized representative signs power of attorney to receive check.