Self-Insured Claims Reimbursement (Sysco) Application Instructions Please answer all questions. If not applicable, use symbol with N/A. Submit completed applications to the: SIINQ@bwc.state.oh.us or via fax 614-621-1246. You must submit all supporting documentation, or BWC will not consider the Sysco reimbursement request. Self-Insured employer Employer name Address, City, State, ZIP code Policy number 2000 Contact phone number Third-party administrator Company name Address, City, State, ZIP code Email address Contact phone number Contact person Injured worker Injured worker name Address, City, State, ZIP code Claim number Date of injury History: Please submit supporting documentation to include all relevant hearing orders (final determination), positive proof of medical benefits (fee bills with ICD-9 codes) and prescription benefits (check copies) and indemnity payments (check copies). Indicate any recoveries as part of the overpayment credit on the Report of Paid Compensation and Case Reserves (SI-40). If you have more than one type of indemnity, please submit on additional form. Basis for request Total amount and type of indemnity: $_________________________________ From_____________ To_____________ Total Amount of medical: $___________________________________________________________________________ Total Amount of prescriptions: $_______________________________________________________________________ Total amount of request: $____________________________________________________________________________ Is there a final determination? Has claim been settled? Yes Yes No No If no, are negotiations pending? Yes No Signature ____________________________________________________________ Date ______________________ (Requestor) BWC-7252 SI-52 American LegalNet, Inc. www.FormsWorkFlow.com