OhioBWC - Common - Form: (C-94-A)

OhioBWC - Common - Form: (C-94-A) - Introduction

Introduction
Wage Statement
(C-94-A)
The C-94-A form is used to submit the injured worker’s earning information to BWC. Employers can complete this form online and submit it electronically. Injured workers can complete the form online, but must be print and submit it via fax or mail since supporting documentation such as payroll stubs, W-2 forms, or any other proof of earnings must be included. If the injured worker is unable to provide any supporting documentation, the Affidavit section of the Wage Statement should be completed and notarized. If the injured worker has worked for multiple employers this documentation should be attached. When completing the Wage Statement only gross earnings should be entered. Make no deductions for social security, pensions, unemployment insurance, etc.
Required information
When the C-94-A is completed online, the majority of the claim demographic information will be automatically populated on the form. However, the following information is required to submit a C-94-A application online: If wage loss compensation is requested by the injured worker the dates being requested must be listed; If the employee receives meals, lodging, tips, etc. in addition to wages, these should be listed; If employee receives wages, meals, lodging, health and accident benefits or any other employee paid benefits during period of disability these should be listed; The gross earnings for the year immediately prior to injury should be entered where possible. Deductions for social security, pensions, insurance, unemployment, etc., should not be included. Please submit an entire year’s worth of earnings where possible in order for BWC to accurately compute the rate of compensation; If the injured worker did not work during any period in the year prior to injury, the reasons below should be listed (i.e. layoffs, illness, plant shutdown, etc.).

Complete the forms
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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.