Authorization to Receive Workers' Compensation Check Better Workers’ Compensation Built with you in mind. This form can be obtained online at ohiobwc.com Injured worker's name Claim number Attorney's name I.D. number Instructions for completion • This form must be completed in its entirety including the correct claim number. • Any authorization not completed in its entirety, altered but not initialed by the party altering the form, or not filed within the proper time periods specified will not be honored. • The award must be specified. • An authorization must be filed for every claim for which an award is to be made. Time limits for filing are as follows: 1) On any compensation paid pursuant to the filing of a C-92, the authorization must be filed with the application, with the agreement of permanent partial disability, with election, with the Industrial Commission of Ohio (IC) at hearing, or after hearing but prior to the date of mailing of the order. 2) IC order – prior to hearing, or at the hearing. 3) Any order from which there is no appeal or objection period – at the hearing or with application. I hereby authorize and direct BWC to mail directly to my attorney the compensation check in the above numbered claim for the accrued portion of my award as specified - (Check only one block) 1. Temporary total – BWC order ___________ 2. Temporary total – IC hearing dated ___________ 3. Impairment of earning capacity 4. Wage loss 5. % Permanent partial 6. Permanent partial; scheduled losses 7. Permanent total – IC order dated ___________ 8. 9. 10. 11. 12. 13. Lump sum settlement Death award – BWC order __________ Death award – IC hearing dated __________ Change of occupation Facial disfigurement VSSR – Violation of specific safety requirements 14. Application or Motion dated __________ This authorization is with the limitation that my attorney does not have the authority to cash or endorse this check on my behalf. Authorizations will be honored for 18 months from the date executed. An authorization timely filed will be honored for any hearing, appeal, or reconsideration on the original issue. An authorization shall not continue in effect after said award or awards have been paid. Injured worker's signature Date BWC USE This authorization is not honored by BWC because: It was not timely filed Other Claims representative's signature BWC-1360 (Rev. 11/03/2003) C-230 It was not properly completed Office Date American LegalNet, Inc. www.USCourtForms.com