Claim number BWC - 1150 (Rev. Feb. 27, 2018) C - 32 Instructions Do not use this form to request an advancement to pay attorney fees. Use the Application for Lump Sum Payment of Attorney Fees IC - 32 - A. You can submit this form by fax to 1 - 866 - 336 - 8352, or send it to the BWC claims office managing the claim. Once BWC receives this application, we will contact you regarding your re - payment options, if applicable. Once an injured worker or surviving spouse has selected an option for re - payme nt of the advancement, he/she may not change the selection or repay the amount earlier than the selected time frame. Applicant information Complete entire section, and proceed to section 2 1 Address City State ZIP code Email address Preferred contact number Cell Home Select one of the following: I am a surviving spouse applying for a lump sum advancement of my death benefits for my financial relief; I am an injured worker applying for a lump sum advancement for my financial relief or furthering my rehabilitation. If you are an injured worker, which of the following types of compensation are you requesting BWC pay you in advance: Scheduled loss Permanent total disability Percentage of permanent partial disability Financial relief and/or furthering rehabilitation information Complete and proceed to section 3 2 If the request is for payment of the amount owed to creditor(s)/ financial institution(s), please provide the complete name and the exact amount owed below. If the of the estimate or contract of said purchase to this application. Attach a separate sheet if necessary. List the name of creditor/financial institution/vendor name Amount owed or anticipated Exact amount requested $ Please exp lain the special circumstance that exist s to support this request . In addition, describe how this advancement will provide you financial relief or afford you the opportunity to further your rehabilitation. must be notarized 3 I understand any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation as provided by BWC or self - insuring employers, or who knowingly accepts compensation to which that person is not entitled, is subject to criminal prosecution. Under appropriate criminal provisions, he or she may be puni shed by a fine or imprisonment or bot h. I understand in the event BWC grants this lump sum advancement, it will result in a reduction of weekly benefits until I repay the advancement. Applicant signature (Applicant signature must be notarized) Date State of Ohio, coun ty of namely : , being first duly sworn, says that the facts stated in the forgoing application are true. Sworn to and subscribed before me this day of , . Notary public signature American LegalNet, Inc. www.FormsWorkFlow.com