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OhioBWC - Common - Form: (C-140) - Introduction
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Application for Wage Loss Compensation
(C-140)
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| Introduction |
The injured worker uses this form to apply for wage loss compensation. The injured
worker and the physician of record must complete this form. The injured worker
supplies information regarding current work status and employment history. The
physician supplies information regarding the injured worker’s work restrictions
and physical capacity. The C-140 may be completed online, however it must be
printed off for mail or fax submission.
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| Required information |
When the C-140 is completed online, the injured worker’s name, address, telephone
number, date of birth, social security number, claim number, occupation at the
time of injury, and the injury employer’s name, address and telephone number will
be automatically populated on the form. The injured worker will need to verify
that this information is correct. Injured worker information can changed online
by selecting the link to claim demographics, however employer information changes
cannot be made online. Contact BWC at 1-800-OHIOBWC if employer information is
incorrect.
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The following additional information is required from the
injured worker:
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Dates and type of wage loss being applied for;
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Work history information including: employer names,
dates of employment, job titles, reasons for leaving and
earnings.
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The following additional information is required from the
physician:
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Physician information including: name, address and telephone number;
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Injured worker information including: date of last medical examination,
restrictions (permanent and/or temporary) as a result of the allowed conditions
in the claim, duration of temporary restrictions (if applicable), and any other
restrictions (not related to claim);
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Injured worker physical capacity for: sitting, standing, and walking;
bending, squatting, crawling, climbing, reaching; lifting; carrying;
use of hands in repetitive actions such as grasping , pushing and pulling
arm controls, and fine manipultation; and use of feet in repetitive movements
of leg controls.
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| Complete the forms |
The free Adobe Reader
software is required to display and print the application.
Do you have all the required information at hand? If so, you are ready to begin
completing the form. When completing the online form, please use the previous and next
buttons located at the bottom of the page to navigate
through the form.
Begin online form now.
Are you missing some of the required information? If so, you may return here
at a later time when you have all the information you need, and complete
this online form. Or, you may print a blank copy of the form to complete by
hand and either mail or fax it to BWC.
Print a blank form.
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