Waiver Of Appeal Period
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Waiver Of Appeal Period Form. This is a Ohio form and can be use in Employers Workers Comp.
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Tags: Waiver Of Appeal Period, BWC-1231, Ohio Workers Comp, Employers
Waiver of Appeal Period
Instructions
• Please print or type.
• Complete all applicable portions of this form.
• Mail the signed and dated copy to the customer service office where the claim is located.
Injured worker name
Address
Claim Information
Claim number
Date of injury
City
State
Nine-digit ZIP code
City
State
Nine-digit ZIP code
Employer name
Address
Please read the information below before signing this form.
Ohio workers' compensation law permits parties to a claim to waive, in writing, their right to appeal orders issued
by BWC and the Industrial Commission of Ohio (IC). To waive an order's appeal period, all parties must submit
written and signed requests. BWC will not grant waivers without the agreement of all parties to a claim. When all
parties agree to waive their appeal rights, BWC cancels the order's 14-day appeal period.
This request for waiver of appeal applies only to the order specified below, not to all past or future orders affecting the claim. Therefore, waiving your right to appeal an order will not prohibit you from appealing other orders
pertaining to the claim.
❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖
The undersigned agree to waive the right to appeal the order dated
which was issued in the above named claim.
Injured worker/Authorized representative Date
Employer/Authorized representative Date
BWC Administrator/Authorized representative Date
(May only waive appeal rights to IC orders)
BWC-1231 (Rev. 2/06/2009)
C-108
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