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 must be completed by both the injured worker and the employer to finalize a settlement, ensuring that all unresolved issues are suspended while ongoing compensation and medical payments continue until the effective settlement date. If you are ready to fill out this important form, click the button below.
The Ohio C 240 form is a critical document for individuals navigating the workers' compensation landscape in Ohio. This form serves as a Settlement Agreement and Application for Approval of Settlement, specifically for state-fund claims. When an injured worker and their employer agree to settle a claim, they must both sign this application, unless the employer is no longer operating in Ohio. It is essential to note that if the employer transitions to self-insurance, they may incur costs related to the Disabled Workers' Relief Fund (DWRF) as part of the settlement. By submitting this form, both parties consent to suspend all unresolved issues, while ongoing compensation and medical payments continue until the settlement is officially approved. The effective settlement date is determined by the mailing date of the Bureau of Workers' Compensation's (BWC) approval. Additionally, the form outlines responsibilities regarding medical expenses incurred before and after the effective date of the settlement, placing the onus on the state insurance fund for earlier costs and on the injured worker for later ones. For Medicare beneficiaries, the form includes a special notice, emphasizing that Medicare will not cover medical bills for conditions linked to the workers' compensation claim until certain conditions are met. Understanding the implications of the Ohio C 240 form is crucial for both injured workers and employers, as it lays the groundwork for resolving claims effectively and ensuring compliance with state regulations.
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
Employer name
Risk number
Fax number
Employer representative name
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?
Are you receiving medical treatment at this
Who is your treating physician(s)?
Wages at time of injury?
time?
Are you currently working?
If yes, who is your present employer?
What is your present occupation?
What are your present wages?
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)
•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
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.
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
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.
Representative signature
Filling out the Ohio C 240 form is a crucial step in the process of settling a workers' compensation claim with a state-fund employer. This form requires careful attention to detail to ensure that all necessary information is accurately provided. Following these steps will help facilitate the settlement process.
After completing the Ohio C 240 form, it is essential to submit it to the appropriate office and ensure that all parties involved understand their obligations. Keeping copies of the submitted form and any supporting documents is advisable for your records.
The Ohio C 240 form is a Settlement Agreement and Application for Approval of Settlement Agreement, specifically designed for state-fund workers' compensation claims. It allows injured workers and employers to apply for approval to settle claims, ensuring that both parties agree on the terms of the settlement.
Both the injured worker and the employer must sign the form, as required by Ohio Revised Code 4123.65. However, if the employer is no longer in business in Ohio, their signature is not necessary.
After the form is submitted, the Bureau of Workers' Compensation (BWC) will review it. If approved, the settlement becomes effective on the mailing date of the BWC's approval. Until that date, all ongoing compensation and medical payments will continue.
Costs for medical services, hospital bills, drugs, and related prescriptions incurred before the effective settlement date are the responsibility of the state insurance fund, provided they are related to the allowed conditions of the claims. After the effective date, those costs shift to the injured worker.
Medicare will not pay for medical expenses related to conditions covered by the workers' compensation claim until the total medical expenses equal the settlement amount allocated for future medical costs. It's essential for Medicare beneficiaries to understand this before finalizing any settlement.
To facilitate the settlement process, any unpaid bills should be forwarded to the injured worker's managed care organization. It is advisable to include a list or copies of these unpaid bills with the Ohio C 240 form submission.
The employer can indicate their level of agreement with the settlement terms by checking the appropriate box on the form. They may support the settlement, disagree but wish to negotiate, or request that the BWC handle negotiations on their behalf.
If fraud is detected, the BWC retains the right to rescind the settlement agreement. This may lead to the reopening of the claim for an administrative overpayment hearing and potential criminal prosecution.
Neglecting Signatures: One of the most common mistakes is failing to obtain the required signatures from both the injured worker and the employer. This is crucial unless the employer is no longer operating in Ohio.
Incorrect Claim Number: It is essential to accurately list the claim number associated with the settlement. Errors can lead to delays or rejections of the application.
Missing Contact Information: Providing complete and correct contact details for both the injured worker and the employer is vital. Incomplete information can hinder communication and processing.
Failure to Attach Relevant Documents: Not including information on other relevant employers or claims can result in complications. Always attach any necessary documentation to support the application.
Not Specifying Excluded Claims: If there are claims specifically excluded from the settlement, it is important to list them. Omitting this information may cause confusion during the review process.
Ignoring Medicare Requirements: Individuals receiving Medicare benefits must understand that Medicare will not cover medical expenses related to the workers' compensation claim until certain conditions are met. Failing to acknowledge this can lead to unexpected costs.
Inaccurate Settlement Amounts: Entering incorrect requested amounts for the proposed settlement can lead to disputes. Ensure that all figures are accurate and reflect the agreement.
Not Initialing Acknowledgment Box: The injured worker must initial the acknowledgment box confirming they have read and understood the terms. Forgetting this step can invalidate the application.
Missing Deadline for Submission: Each application must be submitted within specific timeframes. Delays can result in the application being denied or requiring resubmission.
The Ohio C 240 form is an essential document used in the settlement of workers' compensation claims, particularly for state-fund claims. When navigating the complexities of these claims, several other forms and documents often accompany the C 240 to ensure a smooth process. Below is a list of these documents, each serving a specific purpose in the settlement procedure.
Understanding these accompanying documents can significantly ease the settlement process for injured workers and employers alike. Each form plays a vital role in ensuring that all parties are informed and that the settlement is executed in compliance with Ohio's workers' compensation laws.
The Ohio C 240 form is similar to the "Settlement Agreement and Release" document, which is often used in various legal contexts. This document serves to finalize the terms of a settlement between parties, ensuring that the injured worker releases the employer from any future claims related to the injury. Like the C 240, the Settlement Agreement and Release requires the injured party to acknowledge the receipt of compensation and agree that no further claims will be pursued. Both documents emphasize the importance of understanding the implications of the settlement, including responsibilities for medical expenses incurred after the settlement date.
Another document akin to the Ohio C 240 is the "Application for Approval of Settlement Agreement." This form is typically utilized in various legal proceedings to seek official approval for a proposed settlement. Much like the C 240, this application requires signatures from both parties involved, ensuring mutual agreement on the terms. It also outlines the specific claims being settled and the amounts allocated for each, mirroring the detailed structure found in the C 240 form. Both documents are essential for formalizing the settlement process and ensuring compliance with legal requirements.
The "Release of Liability" form shares similarities with the Ohio C 240 as well. This document is often used to protect one party from future claims by the other party after a settlement has been reached. Like the C 240, the Release of Liability requires the injured worker to acknowledge their understanding of the terms and conditions of the release. Both forms serve to finalize agreements and prevent any further legal action related to the settled claims, thus providing peace of mind to all parties involved.
The "Compromise and Release Agreement" is another document that aligns closely with the Ohio C 240. This agreement is commonly used in workers' compensation cases to settle disputes over claims. It involves negotiations between the injured worker and the employer to reach a mutually acceptable settlement amount. Similar to the C 240, this document requires both parties to agree on the terms, including the handling of future medical expenses and ongoing compensation. Both forms aim to resolve disputes amicably and efficiently.
The "Medicare Set-Aside Agreement" also parallels the Ohio C 240 form. This document is crucial when settling workers' compensation claims for individuals who are Medicare beneficiaries. It outlines how future medical expenses related to the injury will be handled, ensuring that Medicare does not pay for services that should be covered under the settlement. Like the C 240, this agreement emphasizes the importance of understanding the financial responsibilities post-settlement and requires careful consideration of future medical costs.
Lastly, the "Notice of Claim" is a document that bears resemblance to the Ohio C 240. This notice is typically filed to inform the relevant parties about a claim being made, laying the groundwork for subsequent settlement discussions. While the C 240 is focused on finalizing a settlement, the Notice of Claim serves as the initial step in the claims process. Both documents require clear communication and understanding between the injured worker and the employer, setting the stage for eventual resolution of the claim.
When filling out the Ohio C 240 form, it is essential to approach the process with care. Below are four important dos and don’ts to consider.
There are several misconceptions regarding the Ohio C 240 form, which can lead to confusion for injured workers and employers alike. Below is a list of common misunderstandings, along with clarifications to help navigate the settlement process.
This form is primarily for state-fund claims, but it can also be used in cases involving self-insured employers, provided the appropriate forms are completed and submitted.
While unresolved issues may be suspended, ongoing compensation and medical payments continue until the effective settlement date, which is the date BWC approves the settlement.
If the employer is no longer doing business in Ohio, their signature is not required. However, this is a specific condition that must be confirmed.
Medical expenses incurred before the effective settlement date are the responsibility of the state insurance fund, provided they relate to allowed conditions of the claim. After the effective date, the injured worker assumes responsibility for these costs.
Medicare does not pay for medical bills associated with workers' compensation claims. If a settlement allocates amounts for future medical expenses, Medicare will not cover those until the allocated amount is exhausted.
The process can take time, as it requires approval from the BWC. The timeline for settlement may vary based on the complexity of the case and the responsiveness of the involved parties.
Once the application is submitted, any changes to the settlement terms may require additional negotiation and consent from all parties involved.
While the form does release certain claims, it does not eliminate the injured worker's right to pursue any future claims that may arise from new injuries or conditions unrelated to the current settlement.
The Ohio C 240 form is specifically used to settle workers' compensation claims with state-fund employers.
Both the injured worker and the employer must sign the settlement application, unless the employer is no longer conducting business in Ohio.
When a state-fund claim is settled and the employer becomes self-insured, the Bureau of Workers' Compensation (BWC) charges the self-insuring employer for any settlement attributed to the Disabled Workers' Relief Fund (DWRF).
Filing the application suspends all unresolved issues, but ongoing compensation and medical payments will continue until the effective settlement date, which is the date BWC approves the settlement.
Medical costs incurred before the effective settlement date are covered by the state insurance fund, while costs incurred on or after that date are the responsibility of the injured worker.
Medicare does not cover medical expenses related to workers' compensation claims unless certain conditions regarding settlement amounts are met.
It is essential to submit any unpaid bills to the managed care organization to facilitate the settlement process.