Injured Worker Authorized Representative
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Injured Worker Authorized Representative Form. This is a Ohio form and can be use in Injured Workers Workers Comp.
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Tags: Injured Worker Authorized Representative, BWC-6102, Ohio Workers Comp, Injured Workers
Injured Worker
Authorized Representative
Instructions
• The injured worker and representative must complete this form in its entirety and file it with BWC.
• A valid BWC Representative ID number is required.
• To obtain a valid representative ID number, call the customer assistance desk at 614-466-1958 or 614-466-1563,
or inquire at any BWC customer service office information desk.
Injured worker name
Claim number
Injured worker address
City, State, ZIP code
Date of injury
Phone number
Employer name at date of injury
Representative
Representative name
Representative ID number
Address
Telephone number
City, State, ZIP Code
Representative email address
Fax number
Authorization
I hereby authorize the above representative to represent me in the above claim before BWC and the Industrial Commission of Ohio. This authorization
also entitles this representative to automatically receive correspondence generated in the above claim file.
X
Signature of injured worker
Date of Authorization
BWC-6102 (8/11/2008)
R-2
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