Ohio > Workers Comp > Employers

Self Insured Semiannual report Of Claim Payments BWC-1301 - Ohio

Self Insured Semiannual report Of Claim Payments Form. This is a Ohio form and can be used in Employers Workers Comp .
 Fillable pdf Last Modified 2/10/2010
Get this form for FREE as a print-only pdf

Self-Insured Semiannual Report of Claim Payments Instructions ·Completeoneoftheseformsforeachlost-timeclaimactiveduringthesix-month ·Ifyouneedadditionallistingspace,usebackofthisform. ·Sendcompletedformsto: Ohio Bureau of Workers' Compensation Injuredworkername Employername Claimallowedfor:(listallallowedconditions) periodorafterinjuredworkerhasreturnedtoworkifsoonerthansixmonths. 30 W. Spring St., Columbus, OH 43215-2256 Dateofinjury Thisreportisforsix-monthreporting periodending (Date) BWCclaimnumber BWCpolicynumber Fullweeklywage Averageweeklywage(whenapplicable) Ishandicapreimbursement YesNo requested Disability dates (Enterthedatequitworkandthedateofreturntoworkforeachdisabilityperiodduringthissixmonths.) Date(s)quitwork Date(s)returnto work Compensation paid Type(*see codesbelow) (Ifperiodsareconclusive,giveonlybeginningandendingdates,showtotalnumberofweeks,rate andtotalamountpaid.Ifperiodsarebroken,giveindividualperiod.)Additionalspaceonback Period Number Through ofweeks Weeklyrate ofcomp Weeklyrate ofsetoff Total rate Total amount From Dateofirstpaymentmade inthissix-monthperiod Medical expenses paid Dateoflastpaymentmade inthissix-monthperiod (Foreachtypelistedbelow,givethedollaramountpaidforthissix-monthperiod) Physicianfeebills........................................................................ $ Pharmacybills............................................................................. $ . Hospitalbills................................................................................ $ . Othermedicalexpenses............................................................. $ . Totalofallmedicalexpensespaidforthisperiod.................... $ Certification Iapprovedthesetoffoftemporarytotalcompensationwiththeemployer'swhollyfunded non-occupationalinsuranceprograminaccordancewithOhioRevisedCode4123.56. BWC Use Only Injuredworkersignature Date Bysigningbelow,Idoherebycertifytheabovepaymentshavebeenissuedtotheclaimant and/orservicesprovider(s).Ihavetheauthoritytoexecutethisemployer'sreportandcertify theinformationcontainedhereiniscorrecttothebestofmyinformationandbelief.Irequest handicapreimbursementwhenapplicable. Employersignature Compensation type code C/O - Change of occupation DEATH - Death award DWRF - Disable workers relief fund L/M - Living maintenance Title Date S&A - Sickness and accident (non occupational) SC - Salary continuation TP - Temporary partial TT - Temporary total VSSR - Violation of specific safety requirement WWL - Working wage loss LMWL - Living maintenance wage loss NWWL - Non-working wage loss %PP - Percent permanent partial (Paragraph A) PP - Permanent partial (Paragraph B) PT - Permanent total B WC-1301(Rev.8/4/2009) C-174 American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document
URL
Embed


Popular Searches

  1. Preliminary Change of Ownership Report
  2. Notice and Acknowledgment of Receipt
  3. proof of service of summons
  4. Decree of Dissolution of Marriage
  5. Petition to Expunge
  6. writ of replevin
  7. fee waiver
  8. Income and Expense Declaration
  9. divorce forms
  10. proof of claim

Bookmark and Share