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Get OH BWC-1113 2011-2024

T. • If injured worker is employed by a self-insuring employer, complete this form and mail or fax it to his or her employer. • If injured worker is employed by a state-fund employer, complete this form and mail or fax it to the appropriate managed care organization (MCO). • To determine the appropriate MCO, ask the injured worker or employer to visit BWC’s Web site at www.bwc.ohio.gov, or call BWC at 1-800-644-6292, and listen to the options. • Use this form if this is a request f.

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