Waiver of Appeal Period Instructions Please print or type. Complete all applicable portions of this form. Submit the form by mailing or faxing the signed and dated copy to the customer service office where the claim is located. You may also complete this form online at ohiobwc.com. Claim Information Injured worker name Address Employer name Address City State Nine-digit ZIP code City Date of injury State Claim number Nine-digit ZIP code Please read the information below before signing this form. Ohio workers' compensation law permits parties to a claim to waive, in writing, their right to appeal orders issued by BWC and the Industrial Commission of Ohio (IC). To waive an order's appeal period, the following must be filed in writing. o o o For orders that include the allowance of anything other than compensation, the injured worker and employer must submit a signed waiver. If the employer is out of business in Ohio, only the injured worker must submit a waiver. For orders that include only the allowance of compensation, the employer must submit a signed waiver. If the employer is out of business no waiver is needed. For IC orders, BWC must submit a signed waiver, in addition to the injured worker and/or employer. The injured worker, the employer or attorneys who represent them can sign waivers. Non-attorneys may sign a waiver at the direction of the party they represent, but cannot sign at their independent discretion. When the required parties agree to waive their appeal rights, the order's appeal period automatically expires. This request for waiver of appeal applies only to the order specified below, not to all past or future orders affecting the claim. Therefore, waiving your right to appeal an order will not prohibit you from appealing other orders pertaining to the claim. The undersigned agree to waive the right to appeal the order with the mailing date of which was issued in the above named claim. Injured worker/Authorized representative Date , X I am a non-attorney representative for the injured worker who is signing at the direction of the injured worker. Employer/Authorized representative Date X I am a non-attorney representative for the employer who is signing at the direction of the employer. BWC Administrator/Authorized representative Date X May only waive appeal rights to IC orders. BWC-1231 (Rev. 4/17/2012) C-108 American LegalNet, Inc. www.FormsWorkFlow.com