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C84 form ohio bwc 2026
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- Click ‘Get Form’ to open the C-84 form in the editor.
- Begin by filling out your demographics in Section 1. Include your name, address, claim number, and contact information. This ensures BWC can reach you regarding your application.
- In Section 2, indicate whether you are applying for a new period of temporary total compensation or an extension. If it's a new period, provide the last date you worked and list all medical providers treating you for your work-related disability.
- Proceed to Section 3 to detail your employment information. State your occupation at the time of injury and answer questions about your job status and capabilities.
- In Section 4, consider if you would participate in vocational rehabilitation. Your response will help BWC facilitate your return to work.
- Finally, complete Section 5 by indicating any benefits received during your disability period. Ensure all fields are filled accurately before signing in Section 6.
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