Self-Insured Claims Reimbursement (Sysco) Application {BWC-7252}

BWC-7252 / SI-52 - SELF-INSURED DISALLOWED CLAIMS REIMBURSEMENT APPLICATION. This form is used by self-insured employers to request reimbursement from the Ohio Bureau of Workers' Compensation (BWC) for benefits paid on a workers' compensation claim that was later disallowed. The form requires details about the employer, injured worker, claim number, and payments made for medical benefits, prescriptions, and indemnity. Supporting documentation, such as hearing orders, proof of medical and prescription benefits, and indemnity payments, must be submitted. The form also asks whether the claim has been settled or if negotiations are pending. www.FormsWorkflow.com