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.

You may submit complaints or allegations of improper claim management by letter, phone or filing the SI-28 with BWC's self-insured department in Columbus. If you fill out the the SI-28 online, you must download and print the form, include any supporting documentation and mail or fax it to the self-insured department. It's important to complete all sections of this form with as much information as possible.

Note: We'll 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.

• Injured worker name: first, middle, last
• Social Security number
• Mailing address

• Employer name
• Mailing address
• Telephone number

• Date of contact
• Contact person
• Description of your concern
• Employer response

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're ready to fill out the form online. Please use the previous and next buttons located at the bottom of the page to navigate through the form.
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