Employer Authorized Representative
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Employer Authorized Representative Form. This is a Ohio form and can be use in Employers Workers Comp.
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Tags: Employer Authorized Representative, BWC-6101, Ohio Workers Comp, Employers
Employer
Authorized Representative
INSTRUCTIONS:
• This form must be completed in its entirety by the Employer and Representative and filed with the Ohio Bureau
of Workers’ Compensation (BWC).
• A valid BWC Representative I.D. number is required.
• To obtain a valid Representative I.D. number contact the Central Office, Customer Assistance Desk at 614.466.1958
or 614.466.1563 or inquire at any BWC Customer Service Office Information desk.
Injured worker name
Claim number
Date of injury
Social Security Number
Employer name
Employer policy number
Employer address
City, State, ZIP Code
REPRESENTATIVE
Representative name
Representative I.D. number
Address
Telephone number
City, State, ZIP Code
Representative email address
Fax number
AUTHORIZATION
I hereby authorize the above representative to represent me in the above claim before the Ohio Bureau of Workers’ Compensation and the Industrial Commission of Ohio. This authorization also entitles this Representative to automatically receive correspondence generated in the above
claim file.
X
Signature of employer official granting this authorization
Date of Authorization
BWC-6101 (5/18/2006)
R-1
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