| Title |
Last Updated |
| Request For Cancellation |
February 25, 2015 |
| State Fund Employers Agreement To Accept Claim Assignment |
February 25, 2015 |
| Self-Insured Employers Certification Of Assignment After Initial Allowance |
February 25, 2015 |
| Self-Assessment For 10-Step Business Plan For Safety |
February 25, 2015 |
| Request To Correct Employer And Or Policy Number Assignment |
February 25, 2015 |
| Lump Sum Settlement (LSS) |
February 25, 2015 |
| Filing Of An Allegation Against A Self Insured Employer |
February 25, 2015 |
| Application For Ohio Workers Compensation Coverage |
February 25, 2015 |
| Application For Drug Safety Program |
February 25, 2015 |
| Injured Worker Reimbursement Rates For Travel Expense |
February 25, 2015 |
| Injured Worker Authorized Representative |
February 25, 2015 |
| Outpatient Medication Invoice |
February 25, 2015 |
| Application For Wage Loss Compensation |
February 25, 2015 |
| Rehabilitation Election |
January 20, 2014 |
| Plan Of Action |
January 20, 2014 |
| Lump Sum Settlement (LSS) Direct Reimbursement Payment and Rating Program For Public Employer State Agencies |
January 17, 2014 |
| Labor Lease Transaction Payroll |
January 17, 2014 |
| Handicap Reimbursement Election |
January 17, 2014 |
| Objection To Tentative Order |
August 19, 2013 |
| Self-Insurers Agreement As To Compensation On Account Of Death |
August 19, 2013 |
| Unconditional And Continuing Guarantee |
August 19, 2013 |
| Application For Additional Award For Violation Of Specific Safety Requirement |
August 16, 2013 |
| Amended Payroll Report |
August 16, 2013 |
| Acknowledgment Of The Self Insured Joint Settlement Agreement And Release |
August 7, 2013 |
| Request For Prior Authorization Of Medication Form |
July 15, 2013 |
| Wage Statement |
July 15, 2013 |
| Application For Renewal Of Authorization To Operate As A Self-Insured Risk |
July 15, 2013 |
| Consent To Release Information |
January 10, 2013 |
| Waiver Of Appeal Period |
July 11, 2012 |
| Request For 522 52 Relief |
July 11, 2012 |
| Outside Party CAS Access Request Form |
July 5, 2012 |
| Waiver Of Appeal Period |
July 5, 2012 |
| Application For Drug Free Workplace Program And Drug Free EZ |
July 5, 2012 |
| Physicians Request For Medical Service Or Recommendation For Additional Conditions For Industrial Injury Or Occupational Disease |
August 23, 2011 |
| Request For Medical Information |
August 23, 2011 |
| Labor Lease Transaction Claims |
August 23, 2011 |
| Report Of Paid Compensation And Statistical Information |
April 7, 2011 |
| Vocational Rehabilitation Closure Report |
April 7, 2011 |
| Individualized Vocational Rehabilitation Plan |
April 7, 2011 |
| Request For Additional Medical Documentation For C-9 |
April 7, 2011 |
| Safety Review |
April 7, 2011 |
| Contract For Coverage Of State Agency Of Political Subdivision |
April 7, 2011 |
| Application For Retrospective Rating Plan For Public Employers |
April 7, 2011 |
| Accident Report |
April 7, 2011 |
| Disability Evaluator Application |
April 7, 2011 |
| Request For Medical Information |
March 29, 2011 |
| ACT Enrollment And Direct Deposit Authorization |
March 28, 2011 |
| Additional Information For Death Benefits |
March 28, 2011 |
| Notification Of Business Aquisition Or Merger Or Purchase Or Sale |
January 14, 2011 |
| Annual Death Benefits Questionnaire |
January 14, 2011 |
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