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OhioBWC - Common - Form: (SI-28) - Introduction
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Filing Of Allegation Against A Self-Insured Employer (SI-28)
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Introduction |
Injured workers who believe their self-insuring employer is not or has not
handled their claim appropriately may file a complaint against their
employer. For a complaint to be found valid, the employer must violate a
workers’ compensation rule or law.
The BWC’s self-insured department, located in Columbus, handles allegations of
improper claims management by the self-insuring employer.
Injured workers may submit complaints or allegations of improper claim
management by letter, phone or by filing the SI-28. You now can complete the
SI-28 online. Once you have entered the information online, you will
print and submit the complaint form, and any supporting documentation, to
the self-insured department. It is important to complete all sections of
this form with as much information as possible.
Note: We will provide a copy of this allegation to the employer
along with a request for a response. By law, the employer must respond to
the self-insured department within 14 days of the date they receive notification
of this complaint.
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| Required information |
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Injured worker
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- Injured worker name: first, middle, last
- Social Security number
- Mailing address
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Employer
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- Employer name
- Mailing address
- Telephone number
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Employer contact (if applicable)
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- Date of contact
- Contact person
- Description of your concern
- Employer response
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Complete the forms
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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.
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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.
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