Please rate Bwc C84 Form Rev. Feb. 18, 2026
Page 1 holds the instructions and page 2 is the Request for Temporary Total Compensation.
Each request: Complete it every time you make a request for an initial period of temporary total compensation or an extension of an existing period.
Documentation: It is your responsibility to secure supporting medical documentation from your treating provider using the MEDCO-14 form or equivalent documentation.
If you cannot sign: Mark the form and have a witness sign the form next to your mark.
Self-insured employer: If your employer is self-insured, send the form to your employer.
| Question | Answer |
|---|---|
| Form Name | Form C-84 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 68 |
| Avg. time to fill out | 12 min |
| Edition | Feb. 18, 2026 |
| Where to file | If your employer is self-insured, send the form to your employer; for all other injured workers, you may also complete this form online at bwc.ohio.gov; if you have completed a hard copy of this form, fax it to 1-866-336-8352, or send it to the BWC customer service office where the claim is assigned |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | C-84, C84, C-84 form, BWC C-84, Request for Temporary Total Compensation |
| Official source | Form C-84 (Rev Feb. 18, 2026), BWC |
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Please rate Bwc C84 Form Rev. Feb. 18, 2026
