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| To report an injury complete the
following form and click submit. Mandatory
questions are asked in RED. Please fill in as much of this form as
possible to allow us to process quickly.
Warnings:
Any person who obtains compensation from BWC or Self-Insuring employers by:
knowingly misrepresenting or concealing facts, making false statements, or
accepting compensation to which he/she is not entitled, is subject to felony
criminal prosecution for fraud. (R. C.29 13.48).
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| Employer Information |
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