Use this form to request an award for permanent impairment, either physical or psychological, resulting from an allowed workers’ compensation claim. If you have a permanent impairment, you may be eligible for a monetary award based upon the severity of the impairment. You may be eligible for this award even if you did not lose time from work due to the injury.

If you’ve been granted a Percentage of Permanent Partial award previously, you can also use this form to request an increase to that award. Increases may be due to the impairment becoming more severe over time or because a new medical condition has been added to the claim.

Who is this for?

Injured workers who have a permanent impairment can apply based on the severity of impairment.

What you’ll need

• Type of application, i.e. initial percentage of permanent partial disability, determination for a newly allowed condition, or an increase
• Your preferred method of contact
• All days of the week and times of the day you can attend an exam
• Need for an interpreter at the exam
• Your signature for authorization to disburse any monetary award (if applicable)

What you should expect

Upon receiving your completed application, we will review it to ensure you provided all the required information. If necessary, we will ask you to schedule a medical examination to assess the extent of your impairment. Then, we will notify you of the decision regarding your award. Throughout this process, we’ll maintain clear communication to keep you informed of your application’s status.

Completing the form

The easiest and fastest way to complete this form and for us to process it is online using the “Start the online form” button below.

You can also submit a physical form to us in one of the following ways:

• Fax: 614-719-5313
• Mail:
  BWC Mail Processing Center
  Attn: Employer Services
  30 W. Spring St.
  Columbus, OH 43215-2256

Important: If you fax or mail the form to us, be sure to sign and date the form. We cannot process it without a signature.

Helpful resources

Application for Determination or Increase of Percentage of Permanent Partial Disability (C-92) (PDF) – This is a PDF version of this form.

Start the online form