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OhioBWC - Common - Form:  (SI-28) - Introduction

Filing Of Allegation Against A Self-Insured Employer (SI-28)

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.

Required information
Injured worker
  • Injured worker name: first, middle, last
  • Social Security number
  • Mailing address
Employer
  • Employer name
  • Mailing address
  • Telephone number
Employer contact (if applicable)
  • Date of contact
  • Contact person
  • Description of your concern
  • Employer response


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.