en-USC-84 en-USBWC-1205 (Rev. March 12, 2019) en-USInstructionsen-USThis en-USRequest for Temporary Total Compensationen-US (C-84) is the application you complete to request temporary total en-USdisability bene037ts.en-USYou must complete the entire form and sign it. It is your responsibility to secure supporting medical documentation from en-USyour treating provider for the requested period of disability using the MEDCO-14 form or equivalent documentation.en-US en-USYou must complete this form every time you make a request for an initial period of temporary total compensation en-USor an extension of an existing period of temporary total compensation.en-US en-USSection þ en-US1 þ en-USInjured worker demographics:en-US BWC will use the address provided to mail all correspondence to you. en-USA home and/or cell phone number is helpful if we need to contact you. Providing your email address en-USallows you to communicate with your claims specialist electronically, if you choose to do so. Section þ 2 þ en-USDisability information: en-USPlease mark if this current period of disability is a new period of disability en-USor an extension. If this is an application for a new period of disability, please list the last day you en-USworked. For both new periods and requests for extensions of disability, list all providers currently en-UStreating you for this claim. Section þ 3 þ en-USEmployment information: en-USBWC will use this information to help facilitate your return to work and en-USensure proper payment. Section þ 4 þ en-USVocational rehabilitation information: en-USBWC will use this information to help facilitate your return en-USto work. Section þ 5 þ en-USBene037ts/earnings received or requested during the period of disability: en-USIndicate if you have received en-USany of the listed bene037ts. If you answer yes to any of the bene037ts on the list, provide the requested en-USinformation. Section þ 6 þ en-USInjured worker signature:en-US Please sign and date this form when requesting temporary total disability en-UScompensation. If you cannot sign, please mark the form and have a witness sign the form next to en-USyour mark. Signing the form means you have answered the questions truthfully and completely. en-USIt also means you are aware that you are not knowingly making a false statement, misrepresentaen-US-en-UStion, concealment of fact or any other act of fraud to obtain compensation as provided by BWC or en-USknowingly accepting compensation to which you are not entitled. Providing false information or en-USconcealing information to obtain compensation may subject you to felony criminal prosecution, en-USand may be punished by a 037ne, imprisonment, or both.en-US en-USInstructions for Completing the Request for en-USTemporary Total Compensation Where do I 037le the C-84? en-USFor injured workers whose employer is self-insureden-US: If your employer is self-insured, send the form to your employer. en-USIf you are not sure if your employer is a self-insuring employer, contact your employer. en-USFor all other injured workers: en-USYou may also complete this form online at www.bwc.ohio.gov. If you have completed en-USa hard copy of this form, fax it to 1-866-336-8352, or send it to the BWC customer service of037ce where the claim is en-USassigned. en-USWhere do I 037nd more information or assistance?en-USFor injured workers whose employer is self-insured: en-USCall your employer, or contact BWC222s self-insured department en-USat 1-800-644-6292, and listen to the options to reach a customer service representative.en-US en-USFor all other injured workers:en-US Please call 1-800-644-6292, or contact your service of037ce.en-USYou can obtain BWC forms at en-USwww.bwc.ohio.goven-US, by calling 1-800-644-6292 and listening to the options to reach en-USa customer service representative, or at your service of037ce. Spanish speaking American LegalNet, Inc. www.FormsWorkFlow.com en-USDisability information Type of bene037t þ Receiving Beginning date of bene037t en-USC-84 en-USBWC-1205 (Rev. March 12, 2019) en-USRequest for Temporary Totalen-USCompensationen-US5en-USUnemployment en-USIf yes, from which state are you receiving bene037ts? en-USSocial Security retirement en-USPublic assistanceen-USIf yes, include case number: en-USSick leave en-USIf yes, name of company paying the bene037t: en-US en-US en-USWage/salary continuationen-USIf yes, name of company paying the bene037t: en-US en-US en-USDisability en-USIf yes, name of company paying the bene037t: en-USEarnings en-US(to include full or part time, self employment, income-producing hobbies or commission work)en-USIf yes, name of employer en-USand job duties. en-USInjured worker demographics en-USNine-digit ZIP codeen-USAddressen-USCity en-US1en-USNameen-US225 þ Is this application requesting a new period of temporary total compensation or an extension? en-US en-US037en-US New en-US037en-US Extension en-US225 þ If this is a new period, what was the last date worked due to the current period of work-related disability? en-US225 þ List all providers en-UScurrentlyen-US treating you for this work-related disability claim. en-USen-US2en-USStateen-USDate of injuryen-USEmail address (optional)en-USHome phone numberen-US þ­­ 227 en-US þ­ 227 en-US037en-US Yes en-US037en-US No en-US037en-US Yes en-US037en-US No en-US037en-US Yes en-US037en-US No en-US037en-US Yes en-US037en-US No en-US037en-US Yes en-US037en-US No en-US037en-US Yes en-US037en-US No en-US037en-US Yes en-US037en-US No en-USCell phone numberen-US þ­­ 227 en-US þ­ 227 Employment information en-US3 Injured worker signature en-US6en-USI understand I am not permitted to work while receiving temporary total compensation. I have answered the foregoing questions truthfullyen-USand completely. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any otheren-USact of fraud to obtain compensation as provided by BWC or who knowingly accepts compensation to which that person is not entitled isen-USsubject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a 037ne, imprisonment or both. en-USSignatureen-USDate en-USClaim numberen-USBene037ts/earnings received or requested during the period of disability en-USVocational rehabilitation is an individualized and voluntary program for an eligible injured worker who needs assistance in safely returning en-USto work or in retaining employment. This program can be tailored around an injured worker222s restrictions and may provide job-seeking skills en-USor necessary retraining.en-US225 þ If appropriate, would you consider participating in vocational rehabilitation? en-US037en-US Yes en-US037en-US No If no, why not? þ Vocational rehabilitation information en-US4 en-US/ /en-USWhat was your occupation at the time of the injury/disease? 225 þ Do you have a job to return to? en-US037en-US Yes en-US037en-US No en-US037en-US I don222t know o þ en-USIf yes, who is your employer? o þ If yes, does your employer offer modi037ed (light-duty) work? en-US037en-US Yes en-US037en-US No en-US037en-US I don222t know o þ If yes, do you feel capable of performing any of your job duties at this time? en-US037en-US Yes en-US037en-US Noen-USIf yes, what duties? en-USWorking includes full or part-time, self-employment, income-producing hobbies, commission work, or unpaid activities that are not minimal en-USand directly earn income for someone else. 225 þ Are you currently working in any capacity (as de037ned above)? en-US037en-US Yes en-US037en-US No o þ If yes, who is your employer? 225 þ Have you previously worked in any capacity (as de037ned above) during this requested period of disability? en-US037en-US Yes en-US037en-US No o þ If yes, who is your employer? o þ If no, when was the last date you worked anywhere? Reason for leaving 225 þ What do you feel is preventing you from returning to work at this time? Please describe physical, employment and personal barriers. þ en-US/ / American LegalNet, Inc. www.FormsWorkFlow.com