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Settlement Agreement and Application for

Approval of Settlement Agreement

(For state-fund claims only) (Self-insured claims file SI-42)

File this application to settle workers' compensation claims with state-fund employers. Ohio Revised Code 4123.65 requires the injured worker and the employer to sign settlement applications unless the employer is no longer doing business in Ohio. If the claim to be settled is a state-fund claim, and the employer is now self-insuring, BWC charges the self-insuring employer dollar for dollar for any portion of the settlement attributed to past, present or future Disabled Workers' Relief Fund (DWRF) liability.

By iling this application, the injured worker and the employer agree all unresolved issues will be suspended. All ongoing compensation and medical payments, however, will continue until the effective settlement date. The effective settlement date is the mailing date of BWC's approval of settlement agreement.

Please Note: The persons involved with iling this settlement agree if any other claim(s) or part of any claim(s) being settled has been recognized or allowed, then the cost of all medical services, hospital bills, drugs and medicines with date(s) of service or illing of related prescriptions (not to exceed a 30-day supply) provided to the injured worker before the effective settlement date, shall be the responsibility of the state insurance fund, provided such costs result from the allowed conditions of the claims and are properly payable under current medical payment guidelines. The costs of all medical services, hospital bills, drugs and medicine with the date(s) of service of illing of related prescriptions (not to exceed a 30-day supply) provided to the injured worker on or after the effective settlement date are the responsibility of the injured worker.

By initialing this box, the injured worker acknowledges he or she has read and understands the above statement.

Special Notice to Medicare Beneficiaries

Medicare does not pay medical bills for conditions covered by your workers' compensation claim. If a settlement of your workers' compensation claim is reached, and the settlement allocates certain amounts for future medical expenses, Medicare does not pay for those services until medical expenses related to your workers' compensation claim equal the amount of the lump sum settlement allocated to future medical expenses. For additional information, please call the Medicare coordination of beneits contractor at (800) 999-1118.

Instructions

•For lost-time and medical-only claims, mail this completed application to your nearest customer service ofice.

•Call 1-800-OHIOBWC for the address of your local customer service ofice.

•To settle a claim with a self-insuring employer, please complete and forward form SI-42, or contact your self-insuring employer for other forms setting out the agreement between the injured worker and self-insuring employer.

•To facilitate settlement of this claim, please forward any unpaid bills to your managed care organization.

•Include a list of any unpaid bills you are aware of or attach copies of any unpaid bills or statements.

Application for Approval of Settlement Agreement

The injured worker and employer, as agreed to below, make application to BWC for approval of a inal settlement in the injured worker's claim(s).

Parties to the Claim

Injured worker name

Social Security number

Date of birth

Phone number

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

Address

City

 

 

 

State

ZIP code

 

 

 

 

 

 

 

 

Injured worker representative name

 

 

ID number

 

Phone number

 

 

 

 

 

 

(

)

Address

City

 

 

 

State

ZIP code

 

 

 

 

 

 

 

Employer name

Risk number

Fax number

Phone number

 

 

 

 

(

)

(

)

Address

City

 

 

 

State

ZIP code

 

 

 

 

 

 

 

 

Employer representative name

 

 

 

Fax number

Phone number

 

 

 

 

(

)

(

)

Address

City

 

 

 

State

ZIP code

 

 

 

 

 

 

 

 

 

Information on other relevant employers is attached

Yes

No

 

 

 

 

Claim(s) to be Included In Settlement

 

Claim Number*

Requested amount for

 

 

Proposed allocation of requested settlement amount

 

 

 

 

 

 

complete settlement**

 

Indemnity

Prescription drugs

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*List any claims speciically excluded from settlement:

 

 

 

 

 

 

 

 

 

 

**Please explain any request for a partial settlement:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clearly set forth the circumstances by reason of which the proposed settlement is deemed desirable.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has information on other relevant claims been attached?

Are you receiving, or have you applied for Medicare benefits?

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Are you receiving medical treatment at this

Who is your treating physician(s)?

 

Wages at time of injury?

time?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you currently working?

If yes, who is your present employer?

 

What is your present occupation?

What are your present wages?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BWC-1372 (Rev. 2/1/2007)

C-240

Employer Signature

(Required by ORC 4123.65 unless the employer is no longer doing business in Ohio)

Instructions

•Please check one of the following boxes and sign below. Your signature does not waive the employer's right to withdraw consent to the settlement by providing written notice to the employee and the BWC administrator within 30 days after the administrator issues the approval of the settlement agreement.

A. The employer is supportive of and agreeable to a settlement up to the amount listed on the front of this application.

B. The employer does not agree with the requested settlement terms but will participate with the BWC in the negotiation process.

C. The employer is supportive of and agreeable to settlement of the claims listed on the front of this application. However, the employer will not participate in the settlement negotiations and requests the BWC to negotiate the settlement on behalf of the employer.

D. The employer is not agreeable to settlement of the claim(s) listed on the front of this application.

By signing this agreement, an employer that is currently self-insured acknowledges its obligation to reimburse BWC for the portion of the settlement amount allocated to DWRF costs of the above-referenced claim(s). BWC will bill the DWRF portion of the settlement to the self-insuring employer, even if the injured worker has not yet been determined to be permanently and totally disabled or currently eligible for DWRF benefits.

Employer signature

Telephone number

()

Title

Date

 

 

Fax number

()

Settlement Agreement and Release

As set forth in this agreement, the injured worker for and in consideration of the receipt of the settlement amount approved by the BWC, which sum will be paid from the appropriate fund on behalf of the employer after approval by the BWC administrator, unless within 30 days after such approval the administrator, the employer or the injured worker, withdraws consent to, or unless the Industrial Commission of Ohio (IC) disapproves the agreement, does hereby for him/herself and for anyone claiming by, through or under him/her, forever release and discharge the above referenced employer, its oficers, employees, agents, representatives, successors and assigns, the IC, the BWC, the appropriate fund, and all persons, irms or corporations from any or all claims, demands, actions or causes of action incurred on or prior to the date of the approval of this agreement, arising out of Ohio Revised Code Chapter 4121. or 4123., which he/she now has or which he/she hereafter claim to have, whether known or unknown by reason of or in any manner growing out of the claims or parts thereof set forth above. The injured worker further understands and agrees that any amount paid pursuant to this agreement is subject to any valid court-ordered child support. The persons involved with iling this settlement agree that if any claim(s) or part of any claim(s) being settled has been recognized or allowed, then the cost of all medical services, hospital bills, drugs and medicines with date(s) of service or illing of related prescriptions (not to exceed a 30-day supply) provided to the injured worker before the effective settlement date, shall be the responsibility of the state insurance fund, provided such costs result from the allowed conditions of the claims and are properly payable under current medical payment guidelines. The costs of medical services hospital bills, drugs and medicines (not to exceed a 30-day supply) provided to the injured worker on or after the effective date of the settlement date are the responsibility of the injured worker.

By initialing this box, the injured worker acknowledges he or she has read and understands the above statement.

Also as set forth above, the injured worker understands that any settlement amounts allocated for future medical services must be used for medical services before Medicare will consider payment for services for the conditions of the workers' compensation claim.

Settlement of any claim(s) included in this agreement in no way impairs BWC's statutory rights to subrogation recovery. Also, be advised that upon a inding of fraud, the administrator retains the right to rescind this settlement agreement and re-open the claim for an administrative overpayment hearing and referral for criminal prosecution.

Injured worker signature

Date

Power of Attorney

By signing below the injured worker grants a limited power of attorney to the attorney of record for the purpose of receiving the warrant issued because of this settlement agreement.

Injured worker signature

Date

Representative signature

Date

BWC-1372 (Rev. 2/1/2007)

C-240

Document Properties

Fact Name Description
Purpose The Ohio C 240 form is used to apply for approval of a settlement agreement for workers' compensation claims involving state-fund employers.
Governing Law Ohio Revised Code 4123.65 mandates that both the injured worker and employer must sign the settlement application unless the employer is out of business in Ohio.
Settlement Impact By filing this application, unresolved issues are suspended, but ongoing compensation and medical payments will continue until the settlement is effective.
Medicare Notice Medicare does not cover medical expenses for conditions related to the workers' compensation claim until the claim's settlement amount for future medical expenses is exhausted.
Employer Obligations If the employer is self-insured, they are responsible for reimbursing the Bureau of Workers' Compensation for any portion of the settlement related to the Disabled Workers' Relief Fund.

Documents used along the form

The Ohio C 240 form is essential for settling workers' compensation claims with state-fund employers. Alongside this form, there are several other documents that are commonly used to facilitate the settlement process. Below is a list of these forms, along with brief descriptions of each.

  • Form SI-42: This form is specifically for settling claims with self-insured employers. It outlines the agreement between the injured worker and the employer, detailing the terms of the settlement and any obligations that the self-insuring employer may have.
  • Georgia Trailer Bill of Sale: This form is vital for legally documenting the sale of a trailer in Georgia and can be obtained from smarttemplates.net, ensuring both the buyer and seller have a clear record of the transaction.
  • BWC-1372: This is a standard form that may be required for additional information regarding the injured worker's claims. It helps ensure that all relevant claims are included in the settlement process and provides necessary details about the injured worker's current employment status and medical treatment.
  • Settlement Agreement and Release: This document formalizes the agreement reached between the injured worker and the employer. It releases the employer from future claims related to the injury, ensuring that the injured worker understands the implications of the settlement and their rights moving forward.
  • Medicare Coordination of Benefits Form: This form is crucial for injured workers who are also Medicare beneficiaries. It addresses how Medicare will handle medical expenses related to the workers' compensation claim, particularly in terms of future medical costs allocated in the settlement.

These documents work together with the Ohio C 240 form to create a comprehensive framework for settling workers' compensation claims. Understanding each form's purpose can significantly streamline the settlement process and ensure that all parties are well-informed and protected.

Guidelines on Filling in Ohio C 240

Filling out the Ohio C 240 form is an important step in settling a workers' compensation claim with a state-fund employer. It requires accurate information from both the injured worker and the employer. Completing the form correctly will help facilitate the settlement process.

  1. Begin by entering the injured worker's name, Social Security number, date of birth, phone number, and address including city, state, and ZIP code.
  2. If applicable, fill in the injured worker representative's name, ID number, phone number, and address.
  3. Next, provide the employer's name, risk number, fax number, and phone number. Include the employer's address as well.
  4. Include the employer representative's name, fax number, and phone number, along with their address.
  5. Indicate if information on other relevant employers is attached by selecting Yes or No.
  6. List the claim number(s) that will be included in the settlement and the requested amount for complete settlement.
  7. Specify the proposed allocation of the requested settlement amount for indemnity and prescription drugs.
  8. List any claims specifically excluded from the settlement.
  9. If requesting a partial settlement, explain the circumstances justifying it.
  10. Answer whether you are receiving or have applied for Medicare benefits by selecting Yes or No.
  11. Indicate if you are currently receiving medical treatment and provide the name of your treating physician(s).
  12. Answer whether you are currently working, and if so, provide the name of your present employer, occupation, and wages.
  13. Have the employer sign in the required section, selecting one of the options regarding their agreement to the settlement.
  14. Finally, the injured worker must sign and date the settlement agreement, along with any necessary representatives.

Common mistakes

Filling out the Ohio C 240 form can be a straightforward process, but there are common mistakes that individuals often make, which can lead to delays or complications in their workers' compensation claims. Understanding these pitfalls can help ensure that the form is completed correctly.

One frequent error is failing to include all necessary signatures. Both the injured worker and the employer must sign the settlement application unless the employer is no longer doing business in Ohio. Omitting a signature can result in the application being rejected, causing unnecessary delays in processing the claim.

Another common mistake involves not providing accurate or complete information. For instance, the injured worker must include their name, Social Security number, date of birth, and contact details. If any of this information is incorrect or missing, it can lead to complications in verifying the claim and may require resubmission of the form.

People also often neglect to include relevant claim numbers and the requested amounts for settlement. This information is crucial for the Bureau of Workers' Compensation (BWC) to process the application efficiently. Failing to specify which claims are included in the settlement or leaving out the proposed allocation of the settlement amount can lead to confusion and delays.

Additionally, some individuals overlook the importance of attaching supporting documents. If there are unpaid medical bills or other relevant information, these should be included with the application. Not providing this documentation can hinder the approval process and may result in the need for additional follow-up.

Another common mistake is misunderstanding the implications of the settlement. Injured workers must be aware that any medical expenses incurred after the effective settlement date will be their responsibility. Misunderstanding this could lead to unexpected costs and disputes later on.

Lastly, failing to check the box regarding Medicare benefits can create complications. Individuals must indicate whether they are receiving or have applied for Medicare benefits. This information is vital for determining how future medical expenses will be handled, and neglecting it can lead to issues with payment responsibilities.

FAQ

  1. What is the Ohio C 240 form?

    The Ohio C 240 form is a Settlement Agreement and Application for Approval of Settlement Agreement specifically designed for state-fund workers' compensation claims. This form is essential for injured workers and their employers to finalize a settlement regarding compensation claims.

  2. Who needs to sign the Ohio C 240 form?

    Both the injured worker and the employer must sign the Ohio C 240 form, unless the employer is no longer conducting business in Ohio. This requirement ensures that both parties agree to the terms of the settlement.

  3. What happens after filing the Ohio C 240 form?

    Once the form is filed, all unresolved issues related to the claim will be suspended. However, ongoing compensation and medical payments will continue until the effective settlement date, which is the date BWC mails the approval of the settlement agreement.

  4. What are the responsibilities regarding medical expenses after settlement?

    Before the effective settlement date, the state insurance fund is responsible for covering medical services and related costs that result from allowed conditions of the claim. After the effective settlement date, the injured worker becomes responsible for these costs.

  5. What should Medicare beneficiaries know about the Ohio C 240 form?

    Medicare does not cover medical bills for conditions related to a workers' compensation claim. If a settlement allocates funds for future medical expenses, Medicare will only pay for those services after the injured worker's medical expenses equal the allocated settlement amount.

  6. How should I submit the Ohio C 240 form?

    For lost-time and medical-only claims, mail the completed application to your nearest customer service office. You can find the address by calling 1-800-OHIOBWC. If settling a claim with a self-insuring employer, you may need to complete additional forms.

  7. What if the employer does not agree with the settlement terms?

    If the employer disagrees with the requested settlement terms, they can choose to participate in the negotiation process. Alternatively, they can request the BWC to negotiate on their behalf without participating in the discussions.

  8. What is the role of the Bureau of Workers' Compensation (BWC) in this process?

    The BWC reviews the Ohio C 240 form and must approve the settlement agreement. They also handle the billing for any costs associated with the Disabled Workers' Relief Fund (DWRF) for self-insured employers.

  9. What happens if there is a finding of fraud?

    If fraud is detected, the BWC retains the right to rescind the settlement agreement. This may lead to reopening the claim for an administrative overpayment hearing and potential criminal prosecution.