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Initial Application For Wage Loss Compensation BWC-1267 - Ohio

Initial Application For Wage Loss Compensation Form. This is a Ohio form and can be used in Medical Providers Workers Comp .
 Fillable pdf Last Modified 8/10/2009
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INITIAL APPLICATION FOR Better Workers Compensation Built with you in mind. WAGE LOSS COMPENSATION THE FOLLOWING MUST BE ATTACHED WHEN REQUESTING WORKING WAGE LOSSINSTRUCTIONS: File this application when requesting an initial payment of wage loss(WWL) OR NON-WORKING WAGE LOSS (NWWL) OR BOTH: Wage loss statement(s) for job search (C-141)(NWWL). compensation. Proof of registration with the Ohio Department of Jobs and Family Services Complete the form in its entirety. Have the attending physician complete the medical report on the back of(ODJFS)(NWWL). Provide the physician completing this form, a copy of the functional job description this application. at the time of injury (NWWL and WWL). Provide your employer of record (employer at time of injury) with all copies and attachments. Written proof that employment has been sought with your employer of record (NWWL and WWL). Return the completed form to your BWC customer service representative Copies of current pay stubs with gross earnin (WWL)gs. or self-insuring employer. Attach a C-94-A, Wage Statement with signed affidavit (NWWL).Injured worker name Date of birth Claim number Address City State Nine-digit ZIP codeOccupation or job title at time of injury Injured worker telephone numberEmployer name at time of injury Employer telephone numberAddress City State Nine-digit ZIP Code I am requesting working wage loss(WWL ben) efits from ____________ to ____________ I am requesting non-working wage loss(NWWL) benefits from ____________ to ____________ PREVIOUS WORK HISTORY This is required for initial application of WWL and NWWL. Subsequent requests for WWL or NWWL should be submitted on the C-141 Wage Loss Statement. Dates of Reason for Employer Job Title Earnings Employment Leaving 1. 2. 3. 4. 5. 6. . . I hereby certify that the information reported on this Application for Wage Loss Compensation is correct to the best of my knowledge and belief. I have also given a copy of this application and copies of any supporting documentation to my employer of record. WARNING: Any person who obtains compensation from BWC or self-insuring employers by knowingly misrepresenting or concealing factsg f, malseakin statements, or accepting compensation to which he/she is not entitled, is subject to felony criminal prosecution for fraud. Injured worker signature Date BWC-1267 (Rev. 6/4/2003) C-140 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2INSTRUCTIONS TO THE PHYSICIAN: MEDICAL REPORT This medical report will be used as part of an application for wage loss compensation to the Ohio Bureau of Workers Compensation. You may attach any additional information that you feel will help to substantiate this request. This report must be completed by the attending physician and submitted every 90 days if restrictions are temporary or every 180 days if restrictions are permanent. Please complete this report as thoroughly and accurately as possible. Attach additional sheet if necessary. Injured worker name Claim number Name of physician completing this report Telephone number Fax number Address City State Nine-digit ZIP CodeDate of this report Date of last medical examination List all of the allowed conditions in the claim. Identify the injured workers physical restrictions caused by any impairments RESULTING FROM THE ALLOWED PHYSICAL CAPACITY CONDITIONS IN THE CLAIM. For psychiatric/psychological condition(s) please attach a narrative report explaining restrictions. INJURED WORKER CAN: (% of 8 hour workday) TOTAL HOURS DURING AN EIGHT HOUR DAY INJURED WORKER CAN: Never Occasionally Frequently Continuously 0% 1-33% 34-66% 67-100% 0 1 2 3 4 5 6 7 8 Bend Sit Squat Stand Crawl Walk Climb Reach INJURED WORKER CAN LIFT(% o: f 8 hour workday) NRED WORKER CAN CUARRY: (% of 8 hour workday) Never Occasionally Frequently Continuously Never Occasionally Frequently Continuously 0% 1-33% 34-66% 67-100% 0% 1-33% 34-66% 67-100% Up to 5 lbs Up to 5 lbs 6-10 lbs 6-10 lbs 11-20 lbs 11-20 lbs 21-25 lbs 21-25 lbs 26-50 lbs 26-50 lbs 51-100 lbs 51-100 lbs USE OF HANDS IN REPETITIVE ACTION SUCH AS: USE OF FEET IN REPETITIVE MOVEMENTS OF LEG CONTROLS Simple Grasping Pushing and Pulling Arm Controls Fine Manipulation Right Yes No Right Yes No Yes No Yes No Left Yes No Left Yes No Yes No Yes No Both Yes No Based on the allowed conditions of this claim, please listAre the restrictions temporary permanent any additional restrictions not specified in the physical If temporary give an opinion as to the expected capacity section. duration of the restrictions:from to Due to the restrictions noted above, how many total hours per day and per week is the injured worker able to work? ________ Hours ________ Days PHYSICIAN SIGNATURE-MANDATORY I certify that the above information is correct to the best of my knowledge. I am aware that any person who knowingly mfalse statemakes a ent, misrepresenta- tion, concealment of fact or any other act of fraud to obtain payment as provided by BWC or who knowingly accepts paymenich that person is nt to whot entitled is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonm or both.entPhysician signature (Mandatory) Date BWC Provider Number (Mandatory) BWC-1267 (Rev. 6/4/2003) C-140 Pg. 2 American LegalNet, Inc. www.USCourtForms.com
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