Do not use this form to file an appeal to a BWC or IC hearing order. Use Notice of Appeal (IC-12).
Health-care providers: Do not use this form.
Psychiatric: If requesting a psychiatric or psychological condition, please include the statement below. This statement must be signed and dated by the injured worker.
Evidence: You must submit or reference evidence to support the requested action as noted below.
Parties: Parties to the claim include the injured worker, employer and/or their authorized representatives, and BWC.
Certificate of Service: By signing below, I certify I have provided a copy of this Motion to all parties and representatives to the claim.
| Question | Answer |
|---|---|
| Form Name | Form C-86 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 16 |
| Avg. time to fill out | 3 min |
| Edition | Feb. 25, 2026 |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | C-86, C86, C 86, Form C-86, BWC C-86, BWC-1208, C-86 Motion |
| Official source | Form C-86 (Rev Feb. 25, 2026), |
BWC C-86 Form isn’t the one you’re looking for?