State Fund Employers Agreement To Accept Claim Assignment {BWC-1395}

BWC-1395 - STATE FUND EMPLOYER'S AGREEMENT TO ACCEPT CLAIM ASSIGNMENT. This form is used by an Ohio state-fund employer to formally accept the reassignment of a workers’ compensation claim that was previously assigned in error to a different employer. When a claim is mistakenly attributed to the wrong employer by the Ohio Bureau of Workers' Compensation (BWC) or another party, the correct employer must complete and sign this form to assume full responsibility for the claim. By signing, the employer agrees to accept all associated risks and liabilities, including medical benefits and compensation that have been or will be paid under the claim. This form ensures that BWC can officially transfer the claim to the correct employer's policy number and maintain accurate claim records. The signing employer also certifies the accuracy of the information provided and acknowledges potential legal consequences for submitting false or fraudulent information. C-263. www.FormsWorkflow.com