Ohio > Workers Comp > Injured Workers
Application For Payment Of Lump Sum Advancement BWC-1150 - Ohio
| Application For Payment Of Lump Sum Advancement Form. This is a Ohio form and can be used in Injured Workers Workers Comp . |
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Application for Payment of Lump Sum Advancement Instructions · This form is not to be used when requesting advancement of attorney fees. Use the (IC-32A), Application for Lump Sum Payment of Attorney Fees. · Please indicate if you are the injured worker or the injured worker's surviving spouse. · State the exact amount needed and the purposes or reasons the applicant desires the advancement. · Please attach documentation to support request for advancement. Injured worker Name Address City E-mail address State Injured worker surviving spouse · Please specify the type of compensation currently being paid to be advanced. · Applicant signature must be notarized. · Return completed form to the BWC customer service office managing the claim. · Once BWC receives this application, we will contact you regarding your re-payment options. Claim number Telephone number ZIP code Cell phone number Permanent partial (PP) scheduled loss Permanent total disability $ Exact amount requested Death benefits The applicant requests because of special circumstances that BWC pay all or part of the remaining payments of the awarded order in the above referenced claim as a lump sum advancement, which the applicant desires for the purposes and reasons stated below. * The injured worker has the option to have the advancement payable to him or her and a co-payee. If this option is selected, the injured worker must list the co-payee(s) and the exact amount(s) to each. Attach additional sheet if needed. 1. 2. 3. CO-PAYEE AMOUNT I understand that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation as provided by BWC or self-insuring employers, or who knowingly accepts compensation to which that person is not entitled, is subject to criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. The applicant understands that in the event BWC grants this lump sum advancement, it will result in reduction of weekly benefits depending on your repayment option until you repay said advancement. *Exception: The balance of a PP award will be issued in lieu of a reduction in weekly benefits. Applicant signature Date State of Ohio, county of ____________________ __ ss: ________________________________ , being first duly sworn, says that the facts stated in the forgoing application are true. Sworn to and subscribed before me this _______ day of ___________ ______, ______. BWC-1150 (9/22/2010) C-32 Notary Public American LegalNet, Inc. www.FormsWorkFlow.com
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