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OhioBWC - Employer - Service: (SI-40) - Report of Paid Compensation and Case Reserves
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Report of Paid Compensation and Case Reserves (SI-40)
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Once a year, self-insuring employers must complete the
SI-40
online. We'll NO longer accept hard-copy forms. Instead, we'll send an e-mail notice to all self-insuring
employers with a link to the SI every January. Self-insuring employers must submit the information no later
than March 1.
The SI-40 captures all paid compensation the employer has paid in the reporting year by type. Based on the
total amount of paid compensation reported, BWC calculates the self-insuring employer’s semiannual
assessment. The assessment covers safety & hygiene, the administrative cost fund and the surplus fund.
This assessment also covers the portion of the surplus fund used for rehabilitation reimbursement and
handicap reimbursement subject to the self-insuring employer’s election.
Note: Lost-time, Medical-only, Occupational disease and Death fields ask for
the number of claims in the reporting year.
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Required information
- Number of ohio employees
- Number of lost-time claims reported
- Number of medical-only claims reported
- Number of occupational disease claims reported
- Number of death claims reported
- Number of open medical-only claims pre-1987
- Number of open indemnity claims pre-1987
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- Total outstanding case reserves for medical-only claims pre-1987
- Total outstanding case reserves for indemnity claims pre-1987
- Number of open medical-only claims 1987 and post 1987
- Number of open indemnity claims 1987 and post 1987
- Total outstanding case reserves for medical-only claims 1987 and post 1987
- Total outstanding case reserves for indemnity claims 1987 and post 1987
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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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