Self-insured resources

The following are additional resources for the self-insuring (SI) employer.

• Self-insuring PEO – View the requirements for a self-insuring professional employer organization.
• Disallowed Claims Reimbursement (SYSCO SI-52) – View information about the eligibility and reimbursement from the SI portion of the surplus fund under the Sysco case.
• Self-insured workshops – The SI department conducts workshops generally on a quarterly basis for employers and representatives.
• Construction wrap-up projects (SI-50) – View details for self-insuring a construction entity for specific projects.
• SI newsletter – View previous editions of this email newsletter written specifically for the self-insuring community.
• Self-Insured Orientation Tutorial - Employers approved for self-insurance can view information about program requirements. To access the tutorial, you must log in to the BWC Learning Center. If you're a new user of the Learning Center, you must create an account.
• Self-insured policies - View policies applicable to self-insuring employers.
• Self-Insurer's Agreement as to Compensation on Account of Death (C-59) – The self-insuring employer submits this form to BWC or the Ohio Industrial Commission (IC) when it determines the beneficiary or beneficiaries and the benefit rate(s) to be paid as a result of a death due to an injury. All parties must agree before the self-insuring employer submits this form.
• Self-Insured Joint Settlement Agreement and Release (SI-42) – This form sets out the terms of a lump-sum settlement between an injured worker and self-insuring employer. The SI-43 also must accompany this form.
• Acknowledgment of the Self-Insured Joint Settlement Agreement and Release (SI-43) – The injured worker and self-insuring employer use this form to acknowledge their agreement to the lump-sum settlement as detailed on the SI-42.
• Self-Insuring Employer Notice and Request for Information for C-92/C-92A Application (C-256) - Self-insuring employers use this form to respond to BWC when we've received a C-92/C-92A application from one of their employees.
• Self-Insured Employer's Certification of Assignment After Initial Allowance (C-262) – Self-insuring employers complete this form when they are accepting assignment of a claim that BWC or another party mistakenly assigned to another self-insuring employer.
• Self-Insured Employer/Injured Worker Screening (MEDCO-8) – A self-insuring employer uses this form to request a statewide disability screening examination for injured workers who have received 90 consecutive days of temporary total disability compensation.
• Application for Adjustment of Claim in Case of Death Due to Occupational Disease (OD-58-22) – Self-insuring employers submit this form when they cannot determine the correct rate(s) of benefits for the beneficiary or beneficiaries of an injured worker who has died due to a work-related injury. The IC will determine benefit amounts.
• Self-Insured Professional Employer Organization (PEO) Client Relationship Notification (UA-3 SI)