Initial Application for Wage Loss Compensation Instructions File this application when requesting an initial payment of wage loss compensation. • Complete the form in its entirety. • Provide your physician completing this form with a copy of the functional job description at the time of injury and have him or her complete the medical report. • Provide your employer at the time of injury with all copies and attachments. • Return the completed form to your local customer service specialist or your self-insuring employer. You must attach the following when requesting working wage loss (WWL): • Written proof that employment has been sought with your employer of record; • Copies of current pay stubs with gross earnings or a completed C-94-A Wage Statement notarized if completed by the injured worker. You must attach the following when requesting non-working wage loss (NWWL): • Written proof that employment has been sought with your employer of record. • Proof of registration with the Ohio Department of Job and Family Services; • Completed wage loss statement(s) for job search (C-141). Injured worker name Date of birth Address City Claim number State Nine-digit ZIP code Occupation or job title at time of injury Injured worker telephone number Employer name at time of injury Employer telephone number City Address I am requesting WWL benefits from State Nine-digit ZIP code ___________________ to ___________________ I am requesting NWWL benefits from ___________________ to ___________________ Previous work history This is required for initial applications of WWL and NWWL. Please provide your employment history for each position that contributed to your income at a minimum of the last 10 years. (Please attach additional sheets with this information if necessary.) BWC may use this information to determine possible referral for vocational rehabilitation and to evaluate job search efforts. Employer Dates of employment Job title Reason for leaving Earnings 1. 2. 3. 4. 5. 6. 7. 8. Warning I have answered the foregoing questions truthfully and completely. I am aware that 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 felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. I hereby request payment of wage loss benefits for the period listed and certify that the information listed on this Application for Wage Loss Compensation is correct to the best of my knowledge. I have also given a copy of this application with supporting documentation to my employer at the time of injury. Injured worker signature BWC-1267 (Rev. 6/30/2009) C-140 Date American LegalNet, Inc. www.FormsWorkFlow.com Medical Report Instructions for the physician • BWC will use this medical report as part of an application for wage loss compensation. • Please complete this report in its entirety. • Attach additional information that you feel will substantiate this request. • The attending physician must complete and submit this report every 90 days if restrictions are temporary or every 180 days if restrictions are permanent. Claim number Injured worker name Name of physician completing this report Telephone number Fax number Address City State Date of this report Date of last medical examination Nine-digit ZIP code List the allowed conditions in the claim that are causing the restrictions listed below. Indicate only the restrictions caused by any impairment resulting from the allowed conditions. For psychiatric/psychological conditions – attach narrative report outlining restrictions. For physical capacity – denote below. Injured worker can: (% of eight-hour day) Total hours during an eight-hour day injured worker can: 0 1   2 3 4   5         7    8 6 Bend Squat Crawl Climb Reach Sit Stand Walk Injured worker can lift: (% of eight-hour day) Never Occasionally 0% 1%-33% Occasionally 1%-33% Never 0% Continuously 67%-100% Injured worker can carry: (% of eight-hour day) Frequently 34%-66% Never 0% Continuously 67%-100% Occasionally 1%-33% Frequently 34%-66% Continuously 67%-100% Up to 5 lbs 6-10 lbs 11-20 lbs 21-25 lbs 26-50 lbs 51-100 lbs Up to 5 lbs 6-10 lbs 11-20 lbs 21-25 lbs 26-50 lbs 51-100 lbs Use of hands in repetitive action such as: Simple grasping Right Left Frequently 34%-66% Yes Yes Use of feet in repetitive movements of leg controls Pushing and pulling arm controls No No Yes Yes No No Based on the allowed conditions of this claim, please list any additional restrictions not specified in the physical capacity section. Fine manipulation Yes Yes No No Right Left Both Are the restrictions temporary permanent If temporary give an opinion as to the expected duration of the restrictions: from Yes Yes Yes No No No to Due to the restrictions noted above, how many total hours per day and per week can the injured worker work? ________ Hours ________ Days Physician signature (Mandatory) I certify the above information is correct to the best of my knowledge. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment as provided by BWC or who knowingly accepts payment to which that person is not entitled is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. Physician name (Please print) BWC-1267 (Rev. 6/30/2009) C-140 Pg. 2 Physician signature (Mandatory) Date American LegalNet, Inc. www.FormsWorkFlow.com