The Ohio C-240 form, officially titled the Settlement Agreement and Application for Approval of Settlement Agreement, is a critical document for those looking to settle workers' compensation claims with state-fund employers in Ohio. This form is required under Ohio Revised Code 4123.65 and necessitates signatures from both the injured worker and the employer, except in cases where the employer is no longer operational within the state. For claims involving employers that have transitioned to self-insurance, a separate form, the SI-42, needs to be filed, highlighting the form's adaptability based on the employer's current insurance status. Filing this application indicates an agreement between the injured worker and the employer to suspend all unresolved issues, while ongoing compensation and medical payments persist until the settlement is officially approved. The form underscores the responsibility of the state insurance fund to cover the costs of medical services, hospital bills, drugs, and medicines incurred before the settlement's effective date, provided they stem from the allowed conditions of the claims and conform to current medical payment guidelines. Conversely, any costs incurred post-settlement date fall on the injured worker, stressing the importance of understanding the financial implications of the settlement. It also contains a special notice for Medicare beneficiaries regarding the coordination of benefits, emphasizing the form's comprehensive approach to addressing various aspects of settling a workers' compensation claim.
Question | Answer |
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Form Name | Ohio Form C 240 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | C 240 help with ohio workmens comp form c240 |
Settlement Agreement and Application for
Approval of Settlement Agreement
(For
File this application to settle workers' compensation claims with
By iling this application, the injured worker and the employer agree all unresolved issues will be suspended. All ongoing compensation and medical payments, however, will continue until the effective settlement date. The effective settlement date is the mailing date of BWC's approval of settlement agreement.
Please Note: The persons involved with iling this settlement agree if any other claim(s) or part of any claim(s) being settled has been recognized or allowed, then the cost of all medical services, hospital bills, drugs and medicines with date(s) of service or illing of related prescriptions (not to exceed a
By initialing this box, the injured worker acknowledges he or she has read and understands the above statement.
Special Notice to Medicare Beneficiaries
Medicare does not pay medical bills for conditions covered by your workers' compensation claim. If a settlement of your workers' compensation claim is reached, and the settlement allocates certain amounts for future medical expenses, Medicare does not pay for those services until medical expenses related to your workers' compensation claim equal the amount of the lump sum settlement allocated to future medical expenses. For additional information, please call the Medicare coordination of beneits contractor at (800)
Instructions
•For
•Call
•To settle a claim with a
•To facilitate settlement of this claim, please forward any unpaid bills to your managed care organization.
•Include a list of any unpaid bills you are aware of or attach copies of any unpaid bills or statements.
Application for Approval of Settlement Agreement
The injured worker and employer, as agreed to below, make application to BWC for approval of a inal settlement in the injured worker's claim(s).
Parties to the Claim
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Information on other relevant employers is attached |
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Claim(s) to be Included In Settlement
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Proposed allocation of requested settlement amount |
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complete settlement** |
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Indemnity |
Prescription drugs |
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*List any claims speciically excluded from settlement: |
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**Please explain any request for a partial settlement: |
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Clearly set forth the circumstances by reason of which the proposed settlement is deemed desirable. |
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Has information on other relevant claims been attached? |
Are you receiving, or have you applied for Medicare benefits? |
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Are you receiving medical treatment at this |
Who is your treating physician(s)? |
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Wages at time of injury? |
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Are you currently working? |
If yes, who is your present employer? |
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What is your present occupation? |
What are your present wages? |
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Employer Signature
(Required by ORC 4123.65 unless the employer is no longer doing business in Ohio)
Instructions
•Please check one of the following boxes and sign below. Your signature does not waive the employer's right to withdraw consent to the settlement by providing written notice to the employee and the BWC administrator within 30 days after the administrator issues the approval of the settlement agreement.
A. The employer is supportive of and agreeable to a settlement up to the amount listed on the front of this application.
B. The employer does not agree with the requested settlement terms but will participate with the BWC in the negotiation process.
C. The employer is supportive of and agreeable to settlement of the claims listed on the front of this application. However, the employer will not participate in the settlement negotiations and requests the BWC to negotiate the settlement on behalf of the employer.
D. The employer is not agreeable to settlement of the claim(s) listed on the front of this application.
By signing this agreement, an employer that is currently
Employer signature
Telephone number
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Settlement Agreement and Release
As set forth in this agreement, the injured worker for and in consideration of the receipt of the settlement amount approved by the BWC, which sum will be paid from the appropriate fund on behalf of the employer after approval by the BWC administrator, unless within 30 days after such approval the administrator, the employer or the injured worker, withdraws consent to, or unless the Industrial Commission of Ohio (IC) disapproves the agreement, does hereby for him/herself and for anyone claiming by, through or under him/her, forever release and discharge the above referenced employer, its oficers, employees, agents, representatives, successors and assigns, the IC, the BWC, the appropriate fund, and all persons, irms or corporations from any or all claims, demands, actions or causes of action incurred on or prior to the date of the approval of this agreement, arising out of Ohio Revised Code Chapter 4121. or 4123., which he/she now has or which he/she hereafter claim to have, whether known or unknown by reason of or in any manner growing out of the claims or parts thereof set forth above. The injured worker further understands and agrees that any amount paid pursuant to this agreement is subject to any valid
By initialing this box, the injured worker acknowledges he or she has read and understands the above statement.
Also as set forth above, the injured worker understands that any settlement amounts allocated for future medical services must be used for medical services before Medicare will consider payment for services for the conditions of the workers' compensation claim.
Settlement of any claim(s) included in this agreement in no way impairs BWC's statutory rights to subrogation recovery. Also, be advised that upon a inding of fraud, the administrator retains the right to rescind this settlement agreement and
Injured worker signature
Date
Power of Attorney
By signing below the injured worker grants a limited power of attorney to the attorney of record for the purpose of receiving the warrant issued because of this settlement agreement.
Injured worker signature
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Representative signature
Date