Industrial Commission Forms
Quick Links to Forms
|IC-12 Notice of Appeal|
|IC-13 Request for Corrected Order|
|IC-50 Request for Cancellation|
|IC-51 Request for Continuance|
|IC-52 Request for .522/52 Relief|
|IC-2 App. for PTD|
|IC-22 PTD Award Agreement|
|IC-88 App. for Reconsideration|
Description of Forms
NOTE: Adobe Acrobat Reader is required to open these forms.If you do not have Adobe Acrobat Reader, you may download it here for free. Forms can also be requested by calling customer service.
For assistance concerning any of these forms, please contact our Customer Service department.
Appeals can now also be submitted online through I.C.O.N.
Request for Corrected Order
If an IC order contains a clerical or typographical error you can submit the (IC-13) Request for Corrected Order to obtain a corrected order. Please note that this form in not a substitute for an appeal (IC-12). If you disagree with the decision in an order, an appeal should be filed.
Request a new hearing
If the IC ruled on your case and you did not receive proper and timely notice of your hearing, or you did not receive a copy of your order, you may request that the ruling be vacated and a new hearing conducted with the (IC-52) Request for .522/.52 Relief form.
Please mail or fax the form to the Regional Hearing Administrator of the area where your hearing was held or file your request online through I.C.O.N.
Apply for Permanent Total Disability
Injured workers who wish to apply for Permanent Total Disability benefits must submit the (IC-2) Application for Permanent Total Disability and all medical evidence to the local IC office (address provided on the application).
File an agreement as to Permanent Total
When the employer and injured worker agree that the injured worker is permanently and totally disabled due to allowed claim conditions, file the (IC-22) Agreement as to Award for Permanent Total Disability form, including all required signatures, in the local IC office.
Request Permanent Partial Disability
Injured workers or employers who wish to have their permanent partial disability decision reconsidered should mail or fax (IC-88) Application for Reconsideration to the IC office where the hearing took place.
Inform the IC of an address change
Employers and legal representatives can inform the IC of their address changes by mailing or faxing the (EMP-2) Representative/Employer Change of Address form to their local IC office.
Report a safety requirement violation
If an employee has filed an injury claim and the injury occurred because the employer failed to comply with specific safety guidelines outlined in the Ohio Administrative Code, the injured worker may be entitled to additional awards.
Submit the (IC-8/9) Application for Violation of Specific Safety Requirement in Workers' Compensation Claim to the VSSR Claims Examiner (address provided on application) to apply for these awards.
Settle a safety requirement violation
Claims filed for Violation of Specific Safety Requirements in Workers' Compensation Claim (see 'Report a safety requirement violation' above) may be concluded without a hearing if the employer and injured worker agree upon a settlement.
If the two parties agree to a settlement, they may submit the (IC-10) Settlement of Claimed Violation of a Specific Safety Requirement form to a local IC office.
This settlement form also includes a section to waive the right to a hearing and notice of a hearing, and to request an immediate end to any investigation now in progress.
Apply for lump sum payment of legal fees
If permanent total or permanent partial disability is awarded in a claim or a death award is granted, it is possible for the attorney to receive his or her fees in one lump sum by submitting the (IC-32-A) Application for Lump Sum Payment of Attorney Fees to a local IC office.
Request for Interpretive Services
Download the (IC-INT) Interpretive Services Request Form if you require interpretive services. This form allows you to request the type of service you need including sign language and foreign language interpreters.
Interpretive Services can now also be submitted online through I.C.O.N.
Request for Outside Access Form
Employers and representatives may download the (IC-PW) Outside Access Form to request a password to access I.C.O.N. By accessing I.C.O.N., parties may view detailed claim information for claims in the hearing process, request .522 or .52 relief or file an appeal online.
File an agreement as to Compensation for
Permanent Partial Disability
When the parties to the claim agree to a percentage of permanent partial disability of a stated % due to the allowed claim conditions, file the (IC-GC1) Agreement as to Compensation for PPD form, including all required signatures, with the local IC office or Regional Hearing Administrator.
File an Objection
If you would like to file an objection to a BWC tentative order determining the percentage of permanent partial disability compensation in your claim, mail or fax the (IC-167-T) Objection to Tentative Order Form to your local IC office.
Objections can now also be submitted online through I.C.O.N.
Representatives should complete the Employer Photo ID Form in order to be issued
an Industrial Commission Identification Card.
I.C.O.N. is your online resource for managing your hearing file. Logon to file appeals, objections, continuances, cancellations, request services, and view or add documents to your hearing folder.
We're here to help! Call, fax or email us at askIC@ic.ohio.gov with questions and concerns.
Download individual PDFs of IC forms.
Get the information you need to comply with IC rules, resolutions, policies and guidelines.
The Appeals Process
Confused about the process or what is expected of you? Visit the Appeals Process section to learn the ins and outs of workers’ compensation claims and hearings.