Self-Insured Semiannual Report of Claim Payments Instructions ·Completeoneoftheseformsforeachlost-timeclaimactiveduringthesix-month ·Ifyouneedadditionallistingspace,usebackofthisform. ·Sendcompletedformsto: Ohio Bureau of Workers' Compensation Injuredworkername Employername Claimallowedfor:(listallallowedconditions) periodorafterinjuredworkerhasreturnedtoworkifsoonerthansixmonths. 30 W. Spring St., Columbus, OH 43215-2256 Dateofinjury Thisreportisforsix-monthreporting periodending (Date) BWCclaimnumber BWCpolicynumber Fullweeklywage Averageweeklywage(whenapplicable) Ishandicapreimbursement YesNo requested Disability dates (Enterthedatequitworkandthedateofreturntoworkforeachdisabilityperiodduringthissixmonths.) Date(s)quitwork Date(s)returnto work Compensation paid Type(*see codesbelow) (Ifperiodsareconclusive,giveonlybeginningandendingdates,showtotalnumberofweeks,rate andtotalamountpaid.Ifperiodsarebroken,giveindividualperiod.)Additionalspaceonback Period Number Through ofweeks Weeklyrate ofcomp Weeklyrate ofsetoff Total rate Total amount From Dateofirstpaymentmade inthissix-monthperiod Medical expenses paid Dateoflastpaymentmade inthissix-monthperiod (Foreachtypelistedbelow,givethedollaramountpaidforthissix-monthperiod) Physicianfeebills........................................................................ $ Pharmacybills............................................................................. $ . Hospitalbills................................................................................ $ . Othermedicalexpenses............................................................. $ . Totalofallmedicalexpensespaidforthisperiod.................... $ Certification Iapprovedthesetoffoftemporarytotalcompensationwiththeemployer'swhollyfunded non-occupationalinsuranceprograminaccordancewithOhioRevisedCode4123.56. BWC Use Only Injuredworkersignature Date Bysigningbelow,Idoherebycertifytheabovepaymentshavebeenissuedtotheclaimant and/orservicesprovider(s).Ihavetheauthoritytoexecutethisemployer'sreportandcertify theinformationcontainedhereiniscorrecttothebestofmyinformationandbelief.Irequest handicapreimbursementwhenapplicable. Employersignature Compensation type code C/O - Change of occupation DEATH - Death award DWRF - Disable workers relief fund L/M - Living maintenance Title Date S&A - Sickness and accident (non occupational) SC - Salary continuation TP - Temporary partial TT - Temporary total VSSR - Violation of specific safety requirement WWL - Working wage loss LMWL - Living maintenance wage loss NWWL - Non-working wage loss %PP - Percent permanent partial (Paragraph A) PP - Permanent partial (Paragraph B) PT - Permanent total B WC-1301(Rev.8/4/2009) C-174 American LegalNet, Inc. www.FormsWorkFlow.com