Application For Wage Loss Compensation {BWC-1267}

BWC-1267 - APPLICATION FOR WAGE LOSS COMPENSATION. This form is provided by the State of Ohio Bureau of Workers' Compensation. It is used by injured workers to request payment of wage loss benefits. The form requires the injured worker to provide personal details, including their name, address, contact information, and occupation at the time of the injury. Instructions: • You must file this completed application when requesting an initial payment of wage loss compensation or for any requests for wage loss compensation succeeding a broken period. • You must also attach copies of current pay stubs, a payroll report with gross earnings or a completed Employer Report of Earnings for Wage Loss Compensation (C-94A) when requesting working wage loss. • You must also attach proof of job search using the Wage Loss Statement for Job Search (C-141) or equivalent form when requesting non-working wage loss or working wage loss when job search is required. • If BWC is processing your claim, fax the completed form to 1 -866-336-8352, or send it to the BWC customer service office where your claim is assigned. • If a self-insuring employer is processing your claim, send this form directly to your employer. www.FormsWorkflow.com