"Salary Continuation/Oil Appeal Form" - Ohio

Salary Continuation/Oil Appeal Form is a legal document that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio.

Form Details:

  • Released on December 1, 2018;
  • The latest edition currently provided by the Ohio Department of Administrative Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download "Salary Continuation/Oil Appeal Form" - Ohio

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Employee Instructions and Information for completing the
Salary Continuation / OIL Appeal Form
If a request for Salary Continuation (SC) or Occupational Injury Leave (OIL) benefits are denied, the
employee may appeal the denial by completing the Salary Continuation / OIL Appeal Form, as the
employee does not have rights under the grievance procedure.
SC / OIL benefits will end with the denial of the claim and the employee will not be eligible for benefits
during the appeal process.
The employee must have this appeal form submitted within 20 calendar days from the date the
denial letter is postmarked to the Office of Collective Bargaining, attaching additional information to
support the appeal.
Part I – Employee Information
Complete all sections in their entirety
Your name, State of Ohio User ID and home/mailing address
The agency and institution/location where you work
BWC claim number – The claim # assigned by the Ohio Bureau of Workers’ Compensation
Reason for appeal – Be as detailed as possible giving your reason to appeal the decision
Additional information must be attached or the appeal will not be addressed
Appeal form and supporting documents must be submitted within 20 days of the postmark on the
denial letter for appeal to be addressed.
Due to the sensitive nature of the information provided as supportive documentation, this form
and its attachments cannot be faxed or emailed.
DAS Benefits will conduct an initial review of the appeal. DAS Benefits will issue a letter of notification to
the employee and send a copy of the letter, the SC /OIL application and supporting documents to the
Union Central Office notifying the parties of the decision to uphold or reverse the decision.
If the Union determines that further review is necessary, they will submit the request to OCB for a panel to
be convened to review the claim within 10 days of receiving documents from DAS Benefits.
The panel will consist of 3 members, a representative of an agency which is not the employing agency
and who regularly works with SC /OIL, a Union representative not employed by the employing agency,
and a representative or designee of SERB. OCB and Union representatives may attend but will not be
voting members of the panel. The panel will complete a file review of the claim and any information
provided by the employee and make a determination to uphold or overturn the denial. The panel will issue
the decision immediately or within 3 days if further investigation is necessary. The panel’s decision will be
in writing and will be final. The employee or the employer will be involved in the panel.
If the employee accepts Workers’ Compensation temporary total compensation (TT) during the appeal
process, he/she may continue to submit extension paperwork. If the employee’s appeal is upheld, SC/OIL
benefits will be awarded and the agency will work with the employee to repay any Workers’
Compensation TT benefits that were awarded.
Employee Instructions and Information for completing the
Salary Continuation / OIL Appeal Form
If a request for Salary Continuation (SC) or Occupational Injury Leave (OIL) benefits are denied, the
employee may appeal the denial by completing the Salary Continuation / OIL Appeal Form, as the
employee does not have rights under the grievance procedure.
SC / OIL benefits will end with the denial of the claim and the employee will not be eligible for benefits
during the appeal process.
The employee must have this appeal form submitted within 20 calendar days from the date the
denial letter is postmarked to the Office of Collective Bargaining, attaching additional information to
support the appeal.
Part I – Employee Information
Complete all sections in their entirety
Your name, State of Ohio User ID and home/mailing address
The agency and institution/location where you work
BWC claim number – The claim # assigned by the Ohio Bureau of Workers’ Compensation
Reason for appeal – Be as detailed as possible giving your reason to appeal the decision
Additional information must be attached or the appeal will not be addressed
Appeal form and supporting documents must be submitted within 20 days of the postmark on the
denial letter for appeal to be addressed.
Due to the sensitive nature of the information provided as supportive documentation, this form
and its attachments cannot be faxed or emailed.
DAS Benefits will conduct an initial review of the appeal. DAS Benefits will issue a letter of notification to
the employee and send a copy of the letter, the SC /OIL application and supporting documents to the
Union Central Office notifying the parties of the decision to uphold or reverse the decision.
If the Union determines that further review is necessary, they will submit the request to OCB for a panel to
be convened to review the claim within 10 days of receiving documents from DAS Benefits.
The panel will consist of 3 members, a representative of an agency which is not the employing agency
and who regularly works with SC /OIL, a Union representative not employed by the employing agency,
and a representative or designee of SERB. OCB and Union representatives may attend but will not be
voting members of the panel. The panel will complete a file review of the claim and any information
provided by the employee and make a determination to uphold or overturn the denial. The panel will issue
the decision immediately or within 3 days if further investigation is necessary. The panel’s decision will be
in writing and will be final. The employee or the employer will be involved in the panel.
If the employee accepts Workers’ Compensation temporary total compensation (TT) during the appeal
process, he/she may continue to submit extension paperwork. If the employee’s appeal is upheld, SC/OIL
benefits will be awarded and the agency will work with the employee to repay any Workers’
Compensation TT benefits that were awarded.
Salary Continuation / OIL Appeal Form
Part I – Employee Information (completed by employee)
An employee has 20 calendar days from the date the initial denial letter is postmarked to file an appeal
Employee Name:
State of Ohio User ID:
Home Address:
Agency / Location:
BWC Claim #:
Additional information attached?___Yes___ No
Date Denial Received:
Reason for Filing Appeal:
Additional information must be attached or the appeal will not be addressed.
Attention: I acknowledge that employees, whether bargaining unit or exempt, are responsible for adhering to the
contract or policy that governs them and that lack of knowledge of the requirements to receive benefits is not
sufficient reason to reverse the denial of a benefit.
Employee Signature:
Date:
*** Appeal form and supporting documents must be sent to the Office of Collective Bargaining ***
1602 West Broad Street. Columbus, OH 43223
Part II – Union Information (completed by the employee’s Union)
DAS must render a decision within 10 days and send to the Union’s Central Office.
The Union must appeal to OCB within 10 days of receiving documents from DAS Benefits
Appeal to OCB for panel review: (circle)
Yes
No
Date Received:
Comments / Rationale:
Signature:
Date:
SC/OIL Appeal Form (12-2018)
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