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First Report of an Injury, Occupational Disease or Death

WARNING:
Any person who obtains compensation from BWC or self-insuring employers by: knowingly misrepresenting or concealing facts, making false statements, or accepting compensation to which he/she is not entitled, is subject to felony criminal prosecution for fraud.

Injured Worker and Injury/Disease/Death Info

Last Name: First Name: Middle Initial: Social Security Number: Marital Status: Date of Birth:
Single
Married
Divorced
Separated
Widowed   
Home mailing address: Gender:

Number of dependents:

Male
Female

City: State: 9-digit Zip Code: Country: Department name:
Wage rate:   What days of the week do you usually work? Regular work hours:
$ Per: Hour Month
        Week Year
Other
Sun Mon Tue Wed Thur Fri Sat From:

To:
Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau of Workers' Compensation? Occupation or job title:
YES NO If yes, please explain:


Employer name:
Mailing address (number and street, city or town, state, ZIP code and county):
Location, if different from mailing address:
Was place of accident or exposure on employer's premises?
YES NO
If no, give accident location, street address, city, state and ZIP code):
Date of injury/ disease: Time of injury: If fatal, give date of death: Time employee
began work:
Date last worked:
Date returned to work: Date hired: State where hired: Date employer notified:
Description of accident (Describe the sequence of events that directly injured the employee, or caused the disease or death): Type of injury/disease and part(s) of body affected (For example: sprain of lower left back, etc.):


Benefit Application/Medical Release I am applying for recognition of my claim under the Ohio Workers' Compensation Act for work-related injuries that I did not purposely inflict. I request payment for compensation and/or medical expenses as allowable. Direct payment(s) to the providers of any medical services are authorized. I understand that I am allowing any provider who attends to, treats or examines me to release all medical, psychological, and/or psychiatric information that is related causally or historically to physical or mental injuries relevant to issues necessary to the administration of my workers' compensation claim to the Ohio Bureau of Workers' Compensation, the Industrial Commission of Ohio, the employer listed in this claim, that employer's managed care organization, and any authorized representatives. I further authorize the Ohio Rehabilitation Services Commission to release information about my physical, mental, vocational and social conditions that is related causally and historically to physical or mental injuries relevant to issues necessary for the administration of my workers' compensation claim to the aforementioned parties.
Injured worker signature: Date: Telephone number: Work number:


(input name for signature)



Treatment Info

Health care provider name: Telephone number: Fax number: Initial treatment date:
Street address: City: State: 9-digit ZIP code:
Diagnosis(es): Include ICD code(s):
Will the incident cause the injured worker to miss eight or more days of work? Is the injury causally related to the industrial incident?
YES NO YES NO
Health care provider signature: 11-digit BWC provider number: Date:

(input name for signature)


Employer Info

Employer policy number: Check If:
Employer is self-insuring
Injured worker is Owner/Partner/Member of Firm
Telephone number: Fax number: E-mail address: Federal ID number: Manual number:  
 
Was employee treated in an emergency room? Was employee hospitalized overnight as an in-patient?
YES NO YES NO
If treatment was given away from worksite, provide the facility or hospital name, street address, city, state, ZIP code:
FOR SELF-INSURING EMPLOYERS ONLY
   
CERTIFICATION - The employer
certifies that the facts in this
application are correct and valid.
REJECTION - The employer
rejects the validity of this claim for
the following reason(s) below:
CLARIFICATION - The employer clarifies and allows the claim for the condition(s) below:
   
Employer signature: Employer title: Date: OSHA case number:  

(input name for signature)
 


This form meets OSHA 301 requirements