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Injured Workers Change Of Address Notification BWC-1198 - Ohio
| Injured Workers Change Of Address Notification Form. This is a Ohio form and can be used in Injured Workers Workers Comp . |
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Injured Worker's Change of Address Notification Instructions · Please print or type. · Please check the appropriate box in each section. · All information must be completed in order for this form to be processed. · Return this form to your local BWC Customer Service Office as soon as possible. Injured worker name Social Security number Date of injury Injured Worker Information Telephone number ( ) Claim number(s) Date of birth Address City Old Mailing Address Apartment number State Nine-digit ZIP code Address City New Mailing Address Apartment number State Nine-digit ZIP code Please indicate effective date of address change: I certify the information on this form is true and correct. Phone number Cell number E-mail address Injured worker signature Date Date V3 Updated BWC USE ONLY Updated by: Date CAS Updated IC USE ONLY Updated by: BWC-1198 (Rev. 9/22/2010) C-77 American LegalNet, Inc. www.FormsWorkFlow.com
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