Ohio Form Bwc 1217 – Fill Out and Use This PDF

This form was completed by: Employer of record, Injured worker or Other employer.

Enter the Injured worker name, Date of injury and Claim number, then the Phone number and Cell number, the Employer name with its Phone number, and the Email address.

You must provide the Date of hire, even if you are providing weekly earnings on an attached report.

Provide information based on pay period begin and end dates, not payment dates. For the full pay period that ended prior to the date of injury, enter the Pay period begin date and Pay period end date.

During the last seven days of that pay period, enter the Regular earnings, Overtime earnings and Total gross earnings.

Earnings are reported in the periods they are earned, not when they are paid. Some earnings such as bonuses and commissions need to be prorated.

If employed less than one full pay period prior to the date of injury, provide the Number of hours scheduled the week of the injury and the Hourly rate.

Sign on the Signature line after I certify the information provided is correct to the best of my knowledge, then enter the Date and the Employer name and title.

Any person who knowingly makes a false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain payment as provided by the BWC or who knowingly accepts payment 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.

If you are self-employed or unemployed, complete and sign this report, including the affidavit.

In the Affidavit, enter the State of Ohio, County of and the Social Security number: being first duly sworn, says that the entire earnings from ___ to ___ ; is correct.

If unable to write, mark must be witnessed by two persons.

Signature of applicant. Sworn to before me, and subscribed in my presence day of. Official title.

If anyone other than the employer of record in this claim employed the injured worker during the year prior to the date of injury, the injured worker must obtain this information from those employers. If that other employer completes this form, it is not necessary for that employer to complete the affidavit.

If detailed earnings from your employer(s) are not available, you can provide other documentation such as W-2s or Social Security reports. If you submit a 1099, information reported to the IRS or a sworn statement regarding expenses related to that income must accompany it.

BWC will assume earnings submitted on a W-2, Social Security report or 1099 were earned over the entire year unless specifically noted.

Use the worksheet, or attach other documentation to provide earnings information for the 52 weeks prior to the date of injury, beginning with the full pay period prior to the date of injury.

You may submit earnings by providing a report that includes the required information or by completing this worksheet. Report the pay period dates, not the date payment was made. Report any periods the injured worker did not work.

Report earnings beginning with the full pay period that ended prior to the date of injury.

Do not report wages earned on or after the date of injury.

When setting the periods to report, you may adjust the reporting periods backward to line up the reporting time frames with the employer's pay cycle.

If the injured worker received any bonuses, allowances or other payment, describe the nature of the payment and time period over which it was earned. You may also provide other information for BWC to consider in the calculation of FWW and/or AWW such as periods of unemployment.

If payment was made during those periods, report the amount and description of payment the injured worker received.

If the employee received an allowance for meals, lodging, tips, etc in addition to wages, report as other earnings with a description of the earnings.

If the injured worker received a bonus during the reporting period, report as other earnings with a description of the earnings which includes the period of time over which it was earned.

It is not necessary to report reimbursements made to the injured for travel, uniforms, etc. BWC does not consider reimbursements earnings for calculations of wages.

The affidavit may be sworn to without cost before a deputy in a BWC local customer service office.