Form C-262 (BWC-1394) "Self-insured Employer's Certification of Assignment After Initial Allowance" - Ohio

What Is Form C-262 (BWC-1394)?

This is a legal form that was released by the Ohio Bureau of Workers' Compensation - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Ohio Bureau of Workers' Compensation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form C-262 (BWC-1394) by clicking the link below or browse more documents and templates provided by the Ohio Bureau of Workers' Compensation.

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Download Form C-262 (BWC-1394) "Self-insured Employer's Certification of Assignment After Initial Allowance" - Ohio

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Self-Insured Employer’s Certification of
Assignment After Initial Allowance
Instructions
 Complete this form in its entirety when you are accepting assignment of a claim that BWC or another party erroneously assigned to
another self-insured employer.
Injured worker name
Date of injury
Claim number
Employer name
Employer policy number
Employer phone number
Address
City
State
ZIP code
By signing this form, I acknowledge the following:
I understand BWC or another party erroneously assigned the claim to another self-insured employer and, upon execution of
this agreement, will assign it to the policy number listed above.
I accept the responsibility to reimburse______________________________________________________[employer’s name]
__________________________________________________________________________[Address, City, State, ZIP code]
___________________________________[policy number] for all medical benefits and compensation previously paid in this
claim to date and to assume responsibility for any and all future claim costs going forward.
Please include comments or exceptions below.
Comments
I certify the information provided is correct to the best of my knowledge. I am aware that any person who knowingly makes a
false statement, misrepresentation, concealment of fact, or any other act of fraud is subject to felony criminal prosecution and
may, under appropriate criminal provisions, be punished by a fine, imprisonment or both.
Signature
X
Title
Date signed
BWC-1394
C-262
Self-Insured Employer’s Certification of
Assignment After Initial Allowance
Instructions
 Complete this form in its entirety when you are accepting assignment of a claim that BWC or another party erroneously assigned to
another self-insured employer.
Injured worker name
Date of injury
Claim number
Employer name
Employer policy number
Employer phone number
Address
City
State
ZIP code
By signing this form, I acknowledge the following:
I understand BWC or another party erroneously assigned the claim to another self-insured employer and, upon execution of
this agreement, will assign it to the policy number listed above.
I accept the responsibility to reimburse______________________________________________________[employer’s name]
__________________________________________________________________________[Address, City, State, ZIP code]
___________________________________[policy number] for all medical benefits and compensation previously paid in this
claim to date and to assume responsibility for any and all future claim costs going forward.
Please include comments or exceptions below.
Comments
I certify the information provided is correct to the best of my knowledge. I am aware that any person who knowingly makes a
false statement, misrepresentation, concealment of fact, or any other act of fraud is subject to felony criminal prosecution and
may, under appropriate criminal provisions, be punished by a fine, imprisonment or both.
Signature
X
Title
Date signed
BWC-1394
C-262