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Spanish speaking Instructions for Completing the Request ...

C-84 BWC-1205 (Rev. March 12, 2019)InstructionsThis Request for temporary total compensation (C-84) is the application you complete to Request temporary total disability must complete the entire form and sign it. It is your responsibility to secure supporting medical documentation from your treating provider for the requested period of disability using the MEDCO-14 form or equivalent documentation. You must complete this form every time you make a Request for an initial period of temporary total compensation or an extension of an existing period of temporary total compensation . Section 1 Injured worker demographics: BWC will use the address provided to mail all correspondence to you.

You can obtain BWC forms at www.bwc.ohio.gov, by calling 1-800-644-6292 and listening to the options to reach a customer service representative, or at your service office. Spanish speaking. Disability information Type of benefit Receiving Beginning date of benefit C-84 BWC-1205 (Rev. March 12, 2019) Request for Temporary Total Compensation 5 ...

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