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OhioBWC - Worker - Form: (C-141) - Introduction
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Wage Loss Statement for Job Search
(C-141)
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| Introduction |
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Injured workers, who have already applied for or are receiving wage loss, use
this form to document the employers they contact and those results of those
contacts during weekly job searches. BWC bases eligibility for non-working wage
loss compensation on evidence of their continued job search efforts.
Send completed forms to BWC or the self-insuring employer.
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| Required information |
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Dates corresponding to the week of the job search.
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Earnings received from working during the period (if applicable).
- Specific information for each employer contacted during
the job search including: employer name, address, and telephone number;
description of job applied for; contact person; date of contact; method
of contact; and result of contact.
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| Complete the forms |
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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 the BWC.
Print a blank form.
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