Ohio Form Bwc 1217 PDF Details

Navigating the complexities of workplace injuries and the subsequent financial compensation involves a myriad of forms and procedures, among which the Ohio BWC 1217 form, known as the Wage Statement, plays a crucial role. This form serves as a vital document for both injured workers and employers in the wake of a workplace injury, providing a detailed account of the injured worker's earnings prior to the incident. It requires employers to report gross wages, including all forms of earnings such as bonuses, commissions, and pay from holidays, vacation, personal, or sick leave, accurately reflecting the worker's financial situation pre-injury. For injured workers, especially those who are self-employed or were unemployed prior to the injury, the BWC 1217 form is a necessary step in ensuring their compensation rates are accurately determined, warning that failure to file could delay or adversely affect compensation. The instructions laid out for both parties detail the need for thorough documentation, from standard wage reports to possibly requiring affidavits for certain claims, reinforcing the need for accuracy and honesty in the submission process. Furthermore, the form's design to account for various payment frequencies and to include earnings from multiple employers if applicable, highlights its comprehensive nature in capturing a worker's financial earnings landscape. This precision aids in calculating fair compensation rates, demonstrating the form’s pivotal role in the broader context of worker’s compensation and financial recovery post-injury.

Form NameOhio Form Bwc 1217
Form Length3 pages
Fillable fields0
Avg. time to fill out45 sec
Other namesbwc ohio workers compensation, c9 ohio bwc form, ohio wage statement, ohio bwc

Form Preview Example



Wage Statement




Injured worker name

Date of injury

Claim number




Phone number

Cell number





Employer name

Phone number





Email address






Instructions for the employer

Complete and sign this wage statement. It is not necessary for you to complete the affidavit, unless you are also the injured worker.

Report gross earnings. Gross wages include all earnings for the injured worker prior to any deductions such as for taxes, insurance or employee contributions to retirement programs. Include earnings amounts from paid holidays, vacation, personal or sick leave used (but not leave time paid but not used). 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.

Instructions for the injured worker

Failure to file wage statements may delay or adversely affect rates of compensation.

If you are self-employed or unemployed, complete and sign this report, including the affidavit. The affidavit may be sworn to without cost before a deputy in a BWC local customer service office.

If anyone other than the employer of record in this claim employed you during the year prior to the date of injury, you must obtain this information from those employers. If your 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.

This form was completed by:

Employer of record

Injured worker

Other employer

You must provide this information, even if you are providing weekly earnings on an attached report.

Date of hire

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:

Pay period begin date

Pay period end date

During the last seven days of that pay period:

Regular earnings

Overtime earnings

Total gross earnings

If employed less than one full pay period prior to the date of injury, provide the following information:

Number of hours scheduled the week of the injury

Hourly rate

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

Injured worker name

Claim number

BWC-1217 (Rev. 7/30/2012) WAGES formerly known as C-94A

Wage Statement

You may submit earnings by providing a report that includes the required information as described below 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. 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. 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.

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.

Report earnings beginning with the full pay period that ended prior to 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. Do not report wages earned on or after the date of injury.

Payment is made (check one)


Every two weeks

Twice a month



Use the worksheet below, 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.

Pay period end date

Gross amount earned

Other earnings

Description of exceptions






























BWC-1217 (Rev. 7/30/2012)

WAGES formerly known as C-94A

Wage Statement
























I certify the information provided is correct to the best of my knowledge. I am aware that 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.



Employer name and title


Employer signature and title


State of Ohio, County of __________________________________ Social Security number: __________________________________

being first duly sworn, says that the entire earnings from ___________________ to ___________________ ; as listed above is correct.

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

Sworn to before me, and subscribed in my presence

Signature of applicant

day of








Official title

BWC-1217 (Rev. 7/30/2012)

WAGES formerly known as C-94A

How to Edit Ohio Form Bwc 1217 Online for Free

It is possible to create the ohio wage statement form with our PDF editor. The following actions may help you easily prepare your document.

Step 1: On the web page, hit the orange "Get form now" button.

Step 2: You'll find each of the actions that it's possible to undertake on your document once you have accessed the ohio wage statement editing page.

If you want to fill in the ohio wage statement PDF, enter the details for all of the parts:

filling in workersmcomp form step 1

Put down the data in the If you are selfemployed or, This form was completed by You, Employer of record, Other employer, Injured worker, Provide information based on pay, Pay period end date, During the last seven days of that, Overtime earnings, Total gross earnings, If employed less than one full pay, Hourly rate, If the injured worker received any, Injured worker name, and Claim number field.

stage 2 to completing workersmcomp form

The software will ask you to put down some key info to easily fill in the segment Report earnings beginning with, Payment is made check one, Weekly, Every two weeks, Twice a month, Monthly, Other, Use the worksheet below or attach, Pay period end date, Gross amount earned, Other earnings, and Description of exceptions.

Entering details in workersmcomp form stage 3

The area BWC Rev WAGES formerly known as CA will be for you to add both parties' rights and responsibilities.

stage 4 to finishing workersmcomp form

Review the sections and next complete them.

part 5 to finishing workersmcomp form

Step 3: After you pick the Done button, your finished file is easily exportable to any kind of of your devices. Alternatively, you may deliver it by means of mail.

Step 4: To avoid any sort of headaches in the future, be sure to create a minimum of a couple of copies of your file.

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