Fill and Sign the A Self Insured Employer Form

Date of injurySocial Security number Nine-digit ZIP code Claim number Filing of an Allegation Against a Self-insured Employer Inquiry number Policy number Name Address Representative name Address Instructions • Complete all employee and employer information. • Mail the supporting documentation to: Ohio Bureau of W orkers' Compensation Attn. Self-Insured Department 30 W. Spring St., 22nd Floor Columbus, OH 43215-2256 • Fax completed form to: The BWC self-insured department at 614-621-1081 • If a representative is filing the complaint on behalf of the injured worker, the representative MUST attach a copy of his or her Injured Worker Authorized Representative (R-2) card. City City State State Nine-digit ZIP code Telephone number ( ) Telephone number ( ) Employer name Address Employer response City State Nine-digit ZIP code Telephone number ( ) If yes, to whom did you speak Date Injured worker or representative signature Date BWC-7228 (Rev. June 18, 2014) SI-28 Note: We will provide a copy of this allegation to the employer along with a request for a response. By law, the emplo yer must respond to the self-insured department within 14 days of the date he or she receives notification of this complaint. Please state your concern below and attach supporting documents as needed. BWC Use only Employee information Have you contacted your employer about this issue? Yes No Name online form Initial compensation not timely paid in allowed claim 4123-19-03(K)(5) Compensation not paid biweekly 4123-19-03(K)(7) Compensation paid at incorrect rate 4123-19-03(K)(7) Compensation payment refused/delayed in allowed claim 4123-19-03(K)(5) Compensation not paid for entire period of disability (attach copies of C-84s for periods in question) 4123-19-03(K)(7) Employer not responding timely to request for treatment 4123-19-03(K)(5) Employer forces use of vacation/sick leave before paying compensation Other (provide supporting documentation and use other side if needed) Medical bills not timely paid in allowed claim (attach copies of bills) 4123-19-03(K)(5) ORC OAC Employer refuses to acknowledge change in attending physician 4123-19-03(K)(5) Employer refuses to pay travel expenses (attach copy of request) 4123-17-29 Employer refuses to pay living maintenance 4123-19-03(K)(5) Employer improperly terminated compensation without a hearing, without a statement from attending physician regarding maximum medical improvement, and/or permanency of allowed condition 4123-3-32 Employer does not explain or assist injured worker with workers' compensation 4123-19-03(I) Injured worker/representative refused access to claim file 4123-19-03(K)(9) Copy of completed claim application for injured worker not provided by the employer 4123-19-03(K)(3) BWC Use Only