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).  

This form is being completed by:
Name of person reporting injury:
Title of person reporting injury:
Relationship to the injured worker:
What is your email address?  
Employer Identification Number:
Injured Worker Information
Last Name: First Name:
Address: City:
State: Zip:
Home Phone: Work Phone:
E-mail Address: Date of Birth:
SSN: Occupation:
Sex:
Marital Status:
Accident/Disease/Death Information
Date of Injury: Time of Injury:
Date of Death:
Accident Location: Accident Type:
Date Last Worked:   Return to Work Date:  
Accident Description:
Was outside medical treatment sought?

Do you know who provided treatment?   
Treatment Information
Provider: Address:
City: State:
Zip: Phone:  
Initial Treatment Date:   ICD9 Code(s):
Was injury causally related?
Employer Information
Employer Name: Address:
City: State:
Zip: Phone:  
Policy Number: Location/Department: