Ohio > Workers Comp > Injured Workers
Request For Temporary Total Compensation BWC-1205 - Ohio
| Request For Temporary Total Compensation Form. This is a Ohio form and can be used in Injured Workers Workers Comp . |
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Request for Temporary Total Compensation Injured worker demographics Name 1 Address Email address (optional) City Claim number State Home phone number -- -- Date of injury Nine-digit ZIP code Cell phone number -- -- Disability information · Is this application requesting a new period of temporary total compensation or an extension? n New n Extension / / · If this is a new period, what was the last date worked due to the current period of work-related disability? _____________________ 2 · List all providers currently treating you for this work-related disability claim. ________________________________________________________ ________________________________________________________________________________________________________________________________ Employment information What was your occupation at the time of the injury/disease? _________________________________________________________________________ · Do you have a job to return to? n Yes n No n I don't know o If yes, who is your employer? __________________________________________________________________________________________________ o If yes, does your employer offer modified (light-duty) work? n Yes n No n I don't know o If yes, do you feel capable of performing any of your job duties at this time? n Yes n No If yes, what duties? ___________________________________________________________________________________________________________ Working includes full or part-time, self-employment, income-producing hobbies, commission work, or unpaid activities that are not minimal 3 and directly earn income for someone else. · Are you currently working in any capacity (as defined above)? n Yes n No o If yes, who is your employer? __________________________________________________________________________________________________ · Have you previously worked in any capacity (as defined above) during this requested period of disability? n Yes n No o If yes, who is your employer? __________________________________________________________________________________________________ / / o If no, when was the last date you worked anywhere? _____________________ Reason for leaving ____________________________________ · What do you feel is preventing you from returning to work at this time? Please describe physical, employment and personal barriers. ________________________________________________________________________________________________________________________________ Vocational rehabilitation information Vocational rehabilitation is an individualized and voluntary program for an eligible injured worker who needs assistance in safely returning to work or in retaining employment. This program can be tailored around an injured worker's restrictions and may provide job-seeking skills or necessary retraining. 4 · If appropriate, would you consider participating in vocational rehabilitation? n Yes n No If no, why not? ____________________________ ________________________________________________________________________________________________________________________________ Benefits/earnings received or requested during the period of disability Type of benefit Unemployment Receiving Beginning date of benefit If yes, from which state are you receiving benefits? _____________________________________ n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No Social Security retirement Public assistance Sick leave If yes, include case number: ____________________________________________________________ If yes, name of company paying the benefit: _____________________________________________ 5 Wage/salary continuation If yes, name of company paying the benefit: ____________________________________________ Disability If yes, name of company paying the benefit: ____________________________________________ Earnings (to include full or part time, self employment, income-producing hobbies or commission work) If yes, name of employer and job duties. _______________________________________________ Injured worker signature I understand I am not permitted to work while receiving temporary total compensation. I have answered the foregoing questions truthfully and completely. I am aware 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 who knowingly accepts compensation to which that person is not entitled is 6 subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment or both. Date Signature C-84 BWC-1205 (Rev. 6/26/2012) American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing the Request for Temporary Total Compensation This Request for Temporary Total Compensation (C-84) is the application you complete to request temporary total disability benefits. You must complete the entire form and sign it. It is your responsibility to secure supporting medical documentation from your treating provider for the requested period of disability using the MEDCO-14 form or equivalent documentation. You must complete this form every time you make a request for an initial period of temporary total compensation or an extension of an existing period of temporary total compensation. Instructions Section 1 Injured worker demographics: BWC will use the address provided to mail all correspondence to you. A home and/or cell phone number is helpful if we need to contact you. Providing your email address allows you to communicate with your claims specialist electronically, if you choose to do so. Disability information: Please mark if this current period of disability is a new period of disability or an extension. If this is an application for a new period of disability, please list the last day you worked. For both new periods and requests for extensions of disability, list all providers currently treating you for this claim. Employment information: BWC will use this information to help facilitate your return to work and ensure proper payment. Vocational rehabilitation information: BWC will use this information to help facilitate your return to work. Benefits/earnings received or requested during the period of disability: Indicate if you have received any of the listed benefits. If you answer yes to any of the benefits on the list, provide the requested information. Injured worker signature: Please sign and date this form when requesting temporary total disability com
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