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Injured Worker Authorized Representative BWC-6102 - Ohio

Injured Worker Authorized Representative Form. This is a Ohio form and can be used in Injured Workers Workers Comp .
 Fillable pdf Last Modified 2/25/2015
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Injured Worker Authorized Representative You must complete all fields on this form except for the injured worker email address. Complete this form, and fax it to 1-866-336-8352, or send it to the BWC customer service office where your claim is assigned. The form is available online at www.bwc.ohio.gov. Injured worker information Injured worker name Injured worker address City Email address, if available Employer name on the date of injury State Phone number ZIP code Date of injury Claim number Representative information *You may have only one legal representative (one attorney or one law firm) and one union representative. **Your representative must have a BWC representative identification number prior to being designated as an authorized representative. Representative/firm name* Representative BWC ID number** Representative street address City State ZIP code Phone number Authorization I authorize the above to be my authorized representative. The authorization entitles the representative access to my complete claim file, including medical and/or other information contained therein, and to receive correspondence generated in the above claim. I further understand that: If I designate an attorney or law firm, BWC will remove any previously designated attorney or law firm as legal authorized representative, and it is my responsibility to notify the former legal representatives of the change. If I have previously authorized an individual in this claim to receive my workers' compensation check, I understand that, if desired, I must cancel the previous authorization separately in writing. The authorization above is being given to a: Attorney Law firm Union representative Signature of injured worker Other(please explain) Printed name Date of authorization BWC-6102 (Rev. Dec. 27, 2013) R-2 American LegalNet, Inc. www.FormsWorkFlow.com
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