All external IC forms and IC related BWC forms are listed below. For assistance concerning any of these forms, or to request a paper copy, contact customer service.
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.
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.
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 ICON.
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.
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.
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.
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.
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.