Get Employer Authorized Representative R 1 Form

Filling out the Employer Authorized Representative R 1 Form online can seem challenging, but following this guide will help simplify the process. This form is essential for allowing a designated representative to act on behalf of an employer in claims before the Ohio Bureau of Workers’ Compensation.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin with the injured worker's information. Fill in the name of the injured worker, claim number, and date of injury in the designated fields.
3. Provide employer details by entering the employer policy number, employer name, employer address, and city, state, and ZIP code.
4. In the representative section, fill out the representative's name, representative ID number, their address, telephone number, city, state, and ZIP code.
5. Include the representative's email address and fax number in the respective fields.
6. In the authorization section, review the statement and proceed to authorize the representative. Ensure the signature field is completed by the employer official who grants the authorization, along with the date of authorization.
7. Once all sections are filled out accurately, review the information for any errors. After verifying that the details are correct, you can choose to save your changes, download, print, or share the completed form.

Complete your documents online for seamless management.