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OhioBWC - Common - Form: (C-240) - Introduction
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Settlement Agreement and Application for Approval of Settlement Agreement
(C-240)
| Introduction
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A settlement is an agreement between the employer, the injured worker, and BWC for
a specific amount to settle one or more claims. When a claim is fully settled,
the injured worker receives a lump sum payment. The injured worker will receive
no additional compensation and/or benefits for the settled claim. Settlements can
help employers manage costs and bring closure to a claim for injured workers. For
the employer, settlements may also reduce claim costs, which impact premium rates.
Settlements also reduce the number of claims BWC has to manage, thus reducing
overall administrative costs.
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| SPECIAL NOTICE TO MEDICARE BENEFICIARIES
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Medicare does not pay medical bills for conditions covered by your workers'
compensation claim. If a settlement of your workers' compensation claim is
reached, and the settlement allocates certain amounts for future medical expenses
(excluding amounts for prescription drugs), Medicare does not pay for those services
until medical expenses related to your workers' compensation claim equal the amount
of the lump sum settlement allocated to future medical expenses. For additional
information, please call the Medicare Coordination of Benefits Contractor at
1-800-999-1118.
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| Required information
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- Claim number
- Settlement amount
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| Complete the forms
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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.
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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 the BWC.
Print a blank form.
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