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BWC #	Form Title	Description	View/ Print	Online	Order
300AP	Summary of Work-Related Injuries and Illness
AC-18	Labor Lease Transaction - Payroll
AC-19	Labor Lease Transaction - Claims
AC-2	Request to Add/Change or Terminate Permanent Authorization
AC-2-ES	Autorización permanente
AC-3	Temporary Authorization to Review Information
AC-3-ES	Autorización temporaria para la revisión de la información
AC-4	Request for Business Transfer Information
AC-28	Request to Charge the Surplus Fund for Non-At-Fault Motor Vehicle Accident
C-9-A	Request for Additional Medical Documentation for C-9
C-11	ADR Appeal to the MCO Medical Treatment/Service Decision
C-11-ES	Apelación a la decisión por servicio/tratamiento médico de la MCO de ADR
C-18	Notice to BWC of the Injured Worker and Employer Agreement and Authorization to Send Injured Worker's Check(s) to the Employer
C-30	Request for Medical Information
C-55	Salary Continuation Agreement
C-59	Self-Insurer's Agreement as to Compensation on Account of Death
C-86	Motion
C-86-ES	Moción
Wages-EMP	Employer Report of Employee Earnings - formerly Wage Statement (C-94A)
Wages-EMP-ES	Informe del empleador de ingresos del empleado
C-101	Authorization to Release Medical Information
C-101-ES	Autorización para divulger información médica
C-108	Waiver of Appeal
C-110	Employer/Employee Agreement to Select Ohio as the State of Exclusive Remedy for Workers' Compensation Claims
C-112	Employer/Employee Agreement to Select a State Other Than Ohio as the State of Exclusive Remedy for Workers' Compensation Claims
C-142	Employer Report of Employee Earnings for Wage Loss Compensation
C-159	Waiver of Workers' Compensation Benefits for Recreational or Fitness Activities
C-159-ES	Renuncia a los beneficios por indemnización de los trabajadores para actividades recreativas o de ejercicios físicos
C-174	Self-Insured Semiannual Report of Claim Payments
C-240	Settlement Agreement and Application for Approval of Settlement Agreement
C-262	Self-Insured Employer's Certification of Assignment After Initial Allowance
C-263	State Fund Employer's Agreement to Accept Claim Assignment
C-264	Request to Correct Employer and/or Policy Number Assignment
C-512	Notice of intent to Settle
CHP-4A	Application for Handicap Reimbursement
DFSP-1	DFSP Accident Report
DFSP-3	Drug-Free Safety Program (DFSP) Annual Report - Basic and Advanced Levels (sample)
DFSP-4	Drug-Free Safety Program (DFSP) Annual Report - Comparable Program Only (sample)
DFSP-5	DFSP Safety Action Plan
FROI	First Report of an Injury, Occupational Disease or Death
FROI-ES	Informe inicial de lesión, enfermedad ocupacional o fallecimiento
	Reporting fraud
IC-167-T	Objection to Tentative Order Awarding Permanent Partial Disability
LEGAL-15	Application for Adjudication Hearing
LEGAL-16	Settlement Application for Non-complying Employer Claims
	MCO Selection Form
MEDCO-6	Waiver of Examination Statewide Disability Evaluation System
MEDCO-8	Self Insured Employer/Injured Worker Screening
OCP-1	Application for One Claim Program
OD-58-22	Application for Adjustment of Claim in Case of Death Due to Occupational Disease
R-1	Employer Authorized Representative
R-4	Application for Representative Identification Number
RH-5	Trainer's Report
RH-6	On-the-Job Training Agreement
RH-19	Employer Incentive Contract
RH-24	Gradual Return to Work Contract Reimbursement Method
RPS-Amend P/R	Amended True-Up Payroll Report
	Certification safety agreement for sponsors and affiliate sponsors
SA-5	Self-Assessment for the 10-Step Business Plan for Safety
SH-2	Division of Safety & Hygiene Group Experience-and Group-Retrospective-Rating Safety Requirements Annual Report
SH-6	PERRP Complaint Form
SH-12	Sharps Injury Form - Needlestick Report
SH-26	Safety Management Self-Assessment
SH-27	Application for Workplace Wellness Grant Program
SH-28	Application for Industry-Specific Safety Program
SH-53	Application for Safety Intervention Grant
SI-6	Initial Application by Employer for Authority to Pay Compensation Etc. Directly
SI-6S	Application to Add a Subsidiary to an Existing Self-Insured Policy
SI-7	Application for Renewal of Authorization to Operate as a Self-insured Policy
SI-16	Agreement Between Employer and the Ohio Bureau of Workers' Compensation Regarding Amount of Self-Insured Buyout
SI-28	Filing of An Allegation Against a Self-Insured Employer
SI-38	Contract of Guaranty
SI-40	Report of Paid Compensation and Case Reserves
SI-42	Self Insured Joint Settlement Agreement and Release
SI-43	Acknowledgment of the Self-Insured Joint Settlement Agreement and Release
SI-44	Election to Withdraw from Claims Reimbursement Fund
SI-50	Self-Insured Construction Wrap-Up Appplication
SI-51	Application for Certification of Qualified Health Plan (QHP)
SI-52	Self-Insured Claims Reimbursement (Sysco) Application
	Subrogation Referral Form
SUR-1	Substance Use Recovery and Workplace Safety Program Enrollment Form
TWB-1	Application for Transitional Work Bonus Program
TWB-2	Transitional Work Offer and Acceptance Form
TWB-2-ES	Formulario de oferta laboral de transición y aceptación
TWG-1	Application for Transitional Work Grant Program
TWG-2	Transitional Work Grant Reimbursement Request Form
	BWC Service Invoice
	BWC Implementation Invoice
TWG-3	Transitional Work Grant Agreement
TWG-4	Transitional Work Grant Program Corporate Analysis Questionnaire Work Sheet
U-3	Application for Ohio Workers' Compensation Coverage
U-3-ES	Solicitud de Cobertura bajo el seguro de accidentes de trabajo de Ohio
U-3E	Application for Exemption from Ohio Workers' Coverage and Waiver of Benefits
U-3E-ES	Solicitud para la Exención de la Cobertura de la Indemnización de los Trabajadores de Ohio y Renuncia de los Beneficios
U-3S	Application for Elective Coverage
U-3S-ES	Solicitud de Cobertura electiva
UA-3	Professional Employer Organization Client Relationship Notification
UA-3 SI	Self-Insured Professional Employer Organization (PEO) Client Relationship Notification
UA-6	10-Step Business Plan of Action
U-19	Public Employer Agreement for 100-percent EM Cap
U-20	Application for Retrospective Rating Plan for Private Employers
U-21	Application for Retrospective Rating Plan for Public Employers
U-59	Request for Retroactive Coverage and Penalty Abatement or Waiver of Payroll True-Up Penalties
U-69	Contract for Coverage of State Agency or Political Subdivision
U-80	Apprenticeship Elective Coverage Contract
U-108	Opt Out of .99 EM Construction Cap Program
U-117	Notification of Policy Update
U-118	Notification of Business Acquisition/Merger or Purchase/Sale
U-131	Notice of Election to Obtain Coverage from Other States for Employees Working Outside of Ohio
U-140	Application for Drug-Free Safety Program
U-145	Lump Sum Settlement (LSS) Direct Reimbursement Rating and Payment Program for Public Employer State Agencies
U-147	Non-Ohio Amended Payroll Report
U-148	Application for Deductible Program
U-149	Sponsor Certification Application
U-158	Pre-audit Questionnaire and Employer's Authorization
U-158-ES	Cuestionario previo a la auditoria
U-159	Other States Coverage - Trucking Supplemental Application
U-160	Fall Protection in Construction Supplemental Questions