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Filing Of An Allegation Against A Self Insured Employer Form. This is a Ohio form and can be use in Employers Workers Comp.
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Tags: Filing Of An Allegation Against A Self Insured Employer, BWC-7228, Ohio Workers Comp, Employers
Filing of an Allegation
Against
a Self-Insured Employer
Better Workers’ Compensation
Built with you in mind.
Instructions:
•Complete all employee and employer information and forward with supporting
documentation to:
ATTN: Self-Insured Department, Ohio Bureau of Workers' Compensation
30 West Spring Street, Columbus, Ohio 43215-2256
• If a representative is filing the complaint on behalf of the injured worker, the
representative MUST attach a copy of their current authorization card (R-2).
Employee information
Date of injury
Name
BWC Use only
Inquiry #
Policy #
Social Security Number
Claim number
City
State
9-digit ZIP Code
Telephone number
(
)
City
Address
State
9-digit ZIP Code
Telephone number
(
)
Telephone number
Representative name
Address
Employer name
Address
Have you contacted your employer
about this issue?
Yes
No
Employer response
City
State
Name
(
)
9-digit ZIP Code
Date
If yes, to whom did you speak
Please state your concern below and attach supporting documents as needed.
Note: A copy of this allegation will be provided 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 or representative signature
Date
BWC-7228 (Rev. 2/18/2004)
SI-28
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BWC Use Only
Initial compensation not timely paid in allowed
claim 4123-19-03(K)(5)
Compensation not paid biweekly
4123-19-03(K)(7)
Compensation paid at incorrect rate
4123-19-03(K)(7)
Compensation payment refused/delayed in
allowed claim 4123-19-03(K)(5)
Compensation not paid for entire period of
disability (attach copies of C-84s for periods in
question) 4123-19-03(K)(7)
Employer not responding timely to request for
treatment 4123-19-03(K)(5)
Employer forces use of vacation/sick leave
before paying compensation
Other (provide supporting documentation and
use other side if needed)
Medical bills not timely paid in allowed claim
(attach copies of bills) 4123-19-03(K)(5)
Employer refuses to acknowledge change in
attending physician 4123-19-03(K)(5)
Employer refuses to pay travel expenses (attach
copy of request) 4123-17-29
Employer refuses to pay Living Maintenance
4123-19-03(K)(5)
Employer improperly terminated compensation
without a hearing, without a statement from
attending physician regarding maximum
medical improvement, and/or permanency of
allowed condition 4123-3-32
Employer does not explain or assist injured
worker with workers' compensation
4123-19-03(I)
Injured worker/representative refused access to
claim file 4123-19-03(K)(9)
Copy of completed claim application for injured
worker not provided by the employer
4123-19-03(K)(3)
O.R.C
O.A.C.
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