C 27 Form PDF Details

The C 27 form is a document that will allow you to request your military records from the National Personnel Records Center. Some of the information you may find in these records include: personal and family background, education and training history, assignment history, awards and decorations. The process can take up to six months before receiving any documents back. If you are not able to wait that long or if you want copies for other purposes such as genealogy research, then it is best to contact an authorized person who has access to the center's database and order them directly through them instead of going through this process yourself (see below).

Here is the information concerning the file you were in search of to fill out. It can tell you just how long it will take to complete c 27 form, what fields you will need to fill in and some additional specific facts.

QuestionAnswer
Form NameC 27 Form
Form Length2 pages
Fillable?Yes
Fillable fields76
Avg. time to fill out15 min 46 sec
Other namescan chiropractors file c27 form, c 27 workers compensation form, what is a c27 form, workerscomp board c27 form

Form Preview Example

Instructions for Completing the Request for

Temporary Total Compensation

This Request for Temporary Total Compensation (C-84) is the application you complete to request temporary total disability benefits.

You must complete the entire form and sign it. It is your responsibility to secure supporting medical documentation from your treating provider for the requested period of disability using the MEDCO-14 form or equivalent documentation. You must complete this form every time you make a request for an initial period of temporary total compensation or an extension of an existing period of temporary total compensation.

Instructions

Section

1

Injured worker demographics: BWC will use the address provided to mail all correspondence to you.

 

 

A home and/or cell phone number is helpful if we need to contact you. Providing your email address

 

 

allows you to communicate with your claims specialist electronically, if you choose to do so.

 

 

 

Section

2

Disability information: Please mark if this current period of disability is a new period of disability

 

 

or an extension. If this is an application for a new period of disability, please list the last day you

 

 

worked. For both new periods and requests for extensions of disability, list all providers currently

 

 

treating you for this claim.

 

 

 

Section

3

Employment information: BWC will use this information to help facilitate your return to work and

 

 

ensure proper payment.

 

 

 

Section

4

Vocational rehabilitation information: BWC will use this information to help facilitate your return

 

 

to work.

 

 

 

Section

5

Benefits/earnings received or requested during the period of disability: Indicate if you have received

 

 

any of the listed benefits. If you answer yes to any of the benefits on the list, provide the requested

 

 

information.

 

 

 

Section

6

Injured worker signature: Please sign and date this form when requesting temporary total disability

 

 

compensation. If you cannot sign, please mark the form and have a witness sign the form next to

 

 

your mark. Signing the form means you have answered the questions truthfully and completely.

 

 

It also means you are aware that you are not knowingly making a false statement, misrepresenta-

 

 

tion, concealment of fact or any other act of fraud to obtain compensation as provided by BWC or

 

 

knowingly accepting compensation to which you are not entitled. Providing false information or

 

 

concealing information to obtain compensation may subject you to felony criminal prosecution,

 

 

and may be punished by a fine, imprisonment, or both.

 

 

 

Where do I file the C-84?

For injured workers whose employer is self-insured: If your employer is self-insured, send the form to your employer. If you are not sure if your employer is a self-insuring employer, contact your employer.

For all other injured workers: You may also complete this form online at www.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.

Where do I find more information or assistance?

For injured workers whose employer is self-insured: Call your employer, or contact BWC’s self-insured department at 1-800-644-6292, and listen to the options to reach a customer service representative.

For all other injured workers: Please call 1-800-644-6292, or contact your service office.

You can obtain BWC forms at www.bwc.ohio.gov, by calling 1-800-644-6292 and listening to the options to reach a customer service representative, or at your service office.

C-84 BWC-1205 (Rev. March 12, 2019)

Request for Temporary Total

Compensation

Injured worker demographics

1

Name

 

Claim number

 

 

 

Date of injury

 

 

 

 

 

 

 

Address

City

 

State

 

Nine-digit ZIP code

 

 

 

 

 

 

Email address (optional)

 

Home phone number

Cell phone number

 

 

—

—

—

—

 

 

 

 

 

 

 

 

Disability information

2

•Is this application requesting a new period of temporary total compensation or an extension? n New n Extension

•If this is a new period, what was the last date worked due to the current period of work-related disability? _____________________/ /

•List all providers currently treating you for this work-related disability claim. ________________________________________________________

________________________________________________________________________________________________________________________________

Employment information

3

What was your occupation at the time of the injury/disease? _________________________________________________________________________

•Do you have a job to return to? n Yes n No n I don’t know

o If yes, who is your employer? __________________________________________________________________________________________________

o If yes, does your employer offer modified (light-duty) work? n Yes n No n I don’t know o If yes, do you feel capable of performing any of your job duties at this time? n Yes n No

If yes, what duties? ___________________________________________________________________________________________________________

Working includes full or part-time, self-employment, income-producing hobbies, commission work, or unpaid activities that are not minimal and directly earn income for someone else.

•Are you currently working in any capacity (as defined above)? n Yes n No

o If yes, who is your employer? __________________________________________________________________________________________________

•Have you previously worked in any capacity (as defined above) during this requested period of disability? n Yes n No

o If yes, who is your employer? __________________________________________________________________________________________________

o If no, when was the last date you worked anywhere? _____________________/ / Reason for leaving ____________________________________

•What do you feel is preventing you from returning to work at this time? Please describe physical, employment and personal barriers.

________________________________________________________________________________________________________________________________

Vocational rehabilitation information

4

Vocational rehabilitation is an individualized and voluntary program for an eligible injured worker who needs assistance in safely returning to work or in retaining employment.This program can be tailored around an injured worker’s restrictions and may provide job-seeking skills or necessary retraining.

•If appropriate, would you consider participating in vocational rehabilitation? n Yes n No If no, why not? ____________________________

________________________________________________________________________________________________________________________________

Benefits/earnings received or requested during the period of disability

 

Type of benefit

Receiving

Beginning date of benefit

 

 

 

 

 

Unemployment

n Yes n No

 

 

If yes, from which state are you receiving benefits? _____________________________________

 

 

 

 

 

 

Social Security retirement

n Yes n No

 

 

Public assistance

n Yes n No

 

 

If yes, include case number: ____________________________________________________________

 

 

 

 

 

 

Sick leave

n Yes n No

 

 

If yes, name of company paying the benefit: _____________________________________________

 

5

 

 

 

Wage/salary continuation

n Yes n No

 

 

If yes, name of company paying the benefit: ____________________________________________

 

 

 

 

 

 

Disability

n Yes n No

 

 

If yes, name of company paying the benefit: ____________________________________________

 

 

 

 

 

 

Earnings (to include full or part time, self employment, income-producing hobbies or commission work)

n Yes n No

 

 

If yes, name of employer and job duties. _______________________________________________

 

 

Injured worker signature

 

 

6

I understand I am not permitted to work while receiving temporary total compensation. I have answered the foregoing questions truthfully and completely. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation as provided by BWC or who knowingly accepts compensation to which that person is not entitled is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment or both.

Signature

Date

 

 

C-84 BWC-1205 (Rev. March 12, 2019)

How to Edit C 27 Form Online for Free

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Step 1: Choose the orange "Get Form Now" button on the webpage.

Step 2: The form editing page is presently open. You can include information or manage existing details.

Create the what is a c, 27 form PDF and enter the content for every single area:

c27 workers form blanks to consider

Jot down the details in • Have you previously worked in, o If yes, o If no, • What do you feel is preventing, Vocational rehabilitation, Vocational rehabilitation is an, Bene, ts, earnings received or, Type of bene, t Receiving Beginning date of bene, t Unemployment If yes, Social Security retirement, Public assistance If yes, n Yes n No, n Yes n No, and n Yes n No.

Completing c27 workers form step 2

Highlight the most important details of the Wage, salary continuation If yes, n Yes n No, Disability If yes, n Yes n No, Earnings (to include full or part, n Yes n No, Injured worker signature, I understand I am not permitted to, Date, and C, 84 B, WC, 1205 (Rev field.

part 3 to completing c27 workers form

Step 3: Press the button "Done". The PDF form is available to be transferred. You can easily obtain it to your laptop or send it by email.

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