Fill and Sign the Now You Can Have Quick Easy Access to Your Workers Compensation Form

T h is a u th o r iza tio n s h all re m a in i n fu ll fo r ce a n d e ff e c t un t il B WC ha s re c e ive d n o tifi ca tio n fr o m m e o f it s te r mi na t io n or until th ere i s no acc oun t or p aym ent a cti v i ty fo r six mo nths ; aft e r wh i ch this a utho r ization wi ll be terminate d an d all futu re pa ym en ts w i ll b e d elive re d b y c he ck to the las t kn ow n a dd re ss; o r u ntil an au th oriza tion is re ce i v e d by B WC. I a g re e t h a t u n d e r t h e t e rm s o f th i s a g re e m e n t, d e p o s it o f my c o mp e n s a ti o n p a y m e n t(s ) to th is a c c o u n t c o n st itu t e s p a ym e n t t o m e u n de r th e p ro v is io n s o f th e O h io Re v ise d Co de (ORC ) Se c tio n 4 1 2 3. 6 7. By s ig nin g th is ag r e em e n t, I st ate th at I a m e n title d to th e se wo rk er s’ c om p en s atio n be n ef i t s a nd will p rom p tly n o tify BWC s ho u ld I b e co m e in elig ible to re c eiv e su ch p a ym e nt s. WA R NI NG: If yo ur el e ct ro ni c be ne fit card payme nts a re to c o mp en s ate yo u for total d i sa b i li ty, you are n ot en ti tle d to the se pay ments if y ou ar e working. Work ing i nc l udes full or par t-t i m e e m pl oy ment. If you a re r eceiving sur viv o r benefits , or perm anent total compe nsa ti on du e t o th e lo s s of tw o li mbs a n d/or eyesig ht a s provid ed for in OR C Sectio n 412 3.58 , t h is s tatemen t d oes not appl y . Pr int name Sign ature Cl aim number Compl ete, detatch and return t h is postag e-pai d enroll ment ca r d t oda y. Electro nic B e n e fit Ca r d a g ree ment Elect r on ic Benef it Card Elect r on ic Benef it Card N o w y ou ca n h av e q ui ck , ea sy a cce ss to y ou r w o rke rs’ co mp en sa tio n be nef it s t h anks t o t h e E lectr o nic Ben efit Car d , issu ed by the Ohio Bureau of Workers’ Compe nsation (BWC) an d Ch ase. T he Electr o ni c B e n e f i t Ca rd i s a v a i l a b l e t o a l l b e n e f i t r e c i p i e n ts w h o re c e i v e p a y me n t ( s ) from BWC. Wh y yo u sh ou ld r ece ive t he E le ctr on i c Ben efit Card ? Wh y sh ou l d n’t yo u? 1. Pay no more check-c ashi ng fee s ! Receive 100 percent of your benefit. 2. Receive ar o und-t h e- clock ac cess t o your money. Y ou can use t h e E lectronic B e nefit Car d at any bank machin e, anyw h ere (with no ATM fees if used at Chase ma chi nes) . 3. Make bill payments by pho ne. 4. Use it like a credit c ard for ma king pur chas es (only w i t hout the cost l y f inance cha rges) . You don ’t ne ed to have a b ank acco unt . Chas e issues y ou r El ec tronic B en efit Card, w hi c h will directly access your BWC account. You will r eceiv e a per sona l identif ica tion numb er ( P I N) wh en you c all to a ct ivat e your car d, which ensures that only y ou can a ccess you r money. It i s safer than ca rrying cash, and replacing a lost or st o len ca rd is q uick and easy . It ’s e asy t o r ece ive. Just co m p let e t he att ache d, p ost age -pa id fo rm an d mail i t to BWC. Any qu estio ns? • P lease c al l Chase, (877) 25 2- 4 622, with questions a b out your El ect ron ic Benefi t Car d . • F or que s tio ns about your workers’ compensation claim, pl ease call 1-800-OHIOBW C. To re ceiv e Carefully read and sign the Ele c troni c Benefit Ca rd agreemen t and provide your claim numbe r . For qu ick processing of y o ur enrol lment ca rd, b e sure to p r o v i de a l l n ecess ary information . A fter completin g the agreement, sep a rate a t the perfora ti ons and drop it in the mail. It is already addressed and t h e p os tage is paid. No mon thly or a nn ual fee Quick and ea sy ac cess t o your fun ds No wai t ing in line at the bank Timely rece ipt of payme nt s 24 -ho ur ac cess to m o ney Mon thly s t a t e ment s Electro nic bill pay ment Cust omer se rvice 24 ho urs a d a y, ev ery d a y Quick tu rnaro un d for replace ment ca r d World wide ac cept a n c e From (requ i re d) (requ i re d) (requ i re d) No mon thly or a nn ual fee Quick and ea sy ac cess t o your fun ds No wai t ing in line at the bank Timely rece ipt of payme nt s 24 -ho ur ac cess to m o ney Mon thly s t a t e ment s Electro nic bill pay ment Cust omer se rvice 24 ho urs a d a y, ev ery d a y Quick tu rnaro un d for replace ment ca r d World wide ac cept a n c e T h i s a u t h o r i z a t i o n s h a l l r e m a i n i n f u l l f o r c e a n d e f f e c t u n t i l B W C h a s r e c e i v e d n o t i f i c a t i o n f r o m m e o f i t s t e r m i n a t i o n o r u n t i l t h e r e is n o a c c o u n t o r p a y m e n t a c t iv it y f o r s i x m o n t h s ; a f te r w h ic h t h i s a u t h o ri z a t i o n w il l b e t e r m i n a t e d a n d a l l f u t u r e p a y m e n t s w il l b e d e l i v e r e d b y c h e c k t o t h e l a s t k n o w n a d d r e s s ; o r u n t i l a n a u t h o r i z a t i o n i s r e c e iv e d b y BW C . I a g r e e t h a t u n d e r t h e t e r m s o f t h i s a g r e e m e n t , d e p o s i t o f m y c o m p e n s a t i o n p a y m e n t ( s ) t o t h i s a c c o u n t c o n s t i t u t e s p a y m e n t t o m e u n d e r t h e p r o v i s i o n s o f t h e O h i o R e v i s e d C o d e ( O R C ) S e c t i o n 4 1 2 3 . 6 7 . B y s i g n i n g t h i s a g r e e m e n t , I s t a t e t h a t I a m e n t i t l e d t o t h e s e w o r k e r s ’ c o m p e n s a t i o n b e n e f it s a n d w i l l p r o m p t l y n o t i f y B W C s h o u l d I b e c o m e i n e l i g i b l e t o r e c e i v e s u c h p a y m e n t s . W ARN IN G : I f y ou r e lec t r on ic b en ef i t c a r d p a y m en t s a r e t o c om pe ns a t e y ou f o r t o t a l dis a bil it y , y o u a r e no t e nt it l ed t o t h es e p a y m e n t s i f y o u a r e w o r k i n g . W o r k i n g in c lu d e s f u l l o r p a r t - t im e em p lo y m e n t . I f y o u a r e r e c e i v i n g s u r v i v or b e n e f i t s , o r p e r m a n e n t t o t a l c o m p en s a t io n d ue t o t he l os s o f t wo l im b s a nd / o r e y e s i gh t a s p r o v i de d f o r i n O RC S e c t i on 4 1 23 . 5 8, t hi s s t a t e m e nt do e s n o t a p p ly . P r i n t n a m e S i g n a t u r e C la i m n u m b e r C o m p l e t e , d e t a t c h a n d r e t u r n th i s p o s t a g e - p a i d e n r o l l m e n t c a rd to d a y . E l e c t r o n i c B en ef i t C ar d ag r e em e n t N o w y o u c a n h a v e q u i c k , e a s y a c c e s s t o y o u r wo r k e r s ’ c o m p e n s a t i o n b e n e f i ts th a n k s to th e E l e c t ro n i c B e n e f i t C a rd , i s s u e d b y t h e O h i o B u r e a u o f W o r k e r s ’ C o m p e n s a t i o n ( B W C ) a n d C h a s e . T h e E l e c t ro n i c B e n e f i t C a r d i s a v a i l a b l e t o a l l b e n e f i t r e c i p i e n t s w h o r e c e i v e p a y m e n t ( s ) f r o m B W C . W hy y ou s ho ul d re c ei v e th e E l ec t ro ni c B e ne f i t C a r d? W hy s ho ul dn ’ t y ou ? 1 . P a y n o m o r e c h e c k - c a s h in g f e es ! R e c e i v e 1 0 0 p e r c e n t o f y o u r b e n e f i t . 2 . R e c e i v e a r ou n d - t he - c l o c k a c c e s s t o y o u r m o n e y . Yo u c a n u s e t he El e c t r o n i c B en e f i t C a r d a t a n y b a n k m a c h i ne , a n y w he r e ( w i t h n o A T M f e e s i f u s e d a t C h a s e m a c h in e s ) . 3 . M a k e b i l l p a y m e n t s b y p h on e . 4 . U s e i t l i k e a c r e d i t c a r d f o r m a k i n g p u r c h a s e s ( o n l y w it h o u t t h e c o s t ly f i n a n c e c h a r g e s ) . Y o u d o n’ t n ee d t o h a v e a ba n k a c c ou n t. C h a s e i s s u e s y o ur E le c t r o n i c B e ne f i t C a r d , w h ic h w i l l d i r e c t l y a c c e s s y o u r B W C a c c o u n t . Y o u w i l l r e c e i v e a p e r s o n a l i d e n t i f i c a t i o n n u m b e r ( PI N ) w h e n y o u c a l l t o a c t i v a t e y o u r c a r d , w h i c h e n s u r e s t h a t o n l y y o u c a n a c c e s s y o ur m o n e y . I t is s a f e r t h a n c a r r y i n g c a s h , a n d r e p l a c i n g a l o s t o r s t ol e n c a r d i s qu i c k a n d e a s y . I t’ s ea s y to re c ei v e . J u s t c om pl e te th e a t ta c h ed , po s ta g e- p ai d f or m a nd m a i l i t t o B W C . A n y q ue s t i on s ? • Pl e a s e c a ll C h a s e , ( 8 7 7 ) 2 52 - 46 2 2 , w i t h q u e s t i o n s a bo u t y o u r E le c t r o ni c B e n e f it C a r d. • Fo r q u es t i on s a b o u t y o u r w o r k e r s ’ c o m p e n s a t i o n c l a i m , p le a s e c a l l 1 - 8 0 0 - O H I O B W C . T o r ec e i ve C a r e f u l l y r e a d a n d s i g n t h e E l ec t r o n ic B e n e f i t C a r d a g r e e m e nt a n d p r o v i d e y o u r c l a i m n u m b er . F o r q ui c k p r o c e s s i n g o f y ou r e n r o ll m e n t c a r d , be s u r e t o pr ov id e a ll ne c e s s a r y i n f o r m a t i o n. A f t e r c o m p l e t i ng t h e a g r e e m e n t , s e pa r a t e a t t h e p e r f o r a t io n s a n d d r o p i t i n t h e m a i l . I t i s a l r e a d y a d d r e s s e d a n d t he po s t a g e i s p a i d . N o m o n t h l y o r an n u a l f e e Q u i c k a n d e as y a cc e s s t o y o u r f u n d s N o w a it i n g i n l i n e a t t h e b a n k T i m e l y r e c ei p t o f p a y m en t s 2 4- h o u r a cc e s s t o mo n e y M o n t h l y st at em e n t s E l e c t r o n i c b i l l p a ym e n t C u s t o m e r s er v i c e 2 4 h o u r s a d ay , e ve r y d ay Q u i c k t u r n a r o u n d f o r r e p l a c em e n t c ar d W o r l d w i d e a cc e p t an ce From ( r e q u ir e d ) ( r e q u ir e d ) ( r e q u ir e d ) N o m o n t h l y o r an n u a l f e e Q u i c k a n d e as y a cc e s s t o y o u r f u n d s N o w a it i n g i n l i n e a t t h e b a n k T i m e l y r e c ei p t o f p a y m en t s 2 4- h o u r a cc e s s t o mo n e y M o n t h l y st at em e n t s E l e c t r o n i c b i l l p a ym e n t C u s t o m e r s er v i c e 2 4 h o u r s a d ay , e ve r y d ay Q u i c k t u r n a r o u n d f o r r e p l a c em e n t c ar d W o r l d w i d e a cc e p t an ce