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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. A home and/or cell phone number is helpful if we need to contact you. Providing your email address allows you to communicate with your claims specialist electronically, if you choose to do 2 disability information: Please mark if this current period of disability is a new period of disability or an extension.

C-84 BWC-1205 (Rev. March 12, 2019) Instructions This Request for Temporary Total Compensation (C-84) is the application you complete to request temporary total disability benefits. You must complete the entire form and sign it. It is your responsibility to secure supporting medical documentation from

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