Get Wilmapc - Das.ohio.gov

Completing the Wilmapc - Das.ohio.gov form is essential for requesting an extension or reactivation of salary continuation or occupational injury leave benefits. This guide will provide clear instructions on how to accurately fill out the required sections of the form to ensure a smooth application process.

Follow the steps to successfully complete your application online.

1. Press the ‘Get Form’ button to access the form and open it in the appropriate editor.
2. Begin with the Employee Section on page 1 of the form. Complete all requested personal information, including your name, BWC claim number, and date of injury. Ensure that you notify your supervisor of your absence and expected return date.
3. Answer all questions regarding the status of your condition since your last request for benefits. Specify the date of your next doctor's visit and indicate whether your condition has improved, stayed the same, or worsened.
4. Indicate whether you have worked any other jobs since your disability began. If applicable, provide details about your employment.
5. Choose whether you are requesting an extension or reactivation of your benefits. If you are requesting an extension, provide the relevant dates and the type of benefits (salary continuation or occupational injury leave).
6. If applicable, indicate if you have returned to work and provide the actual return date. Discuss your agency’s transitional work program with your doctor if necessary.
7. Complete the appropriate sections for requesting reactivation if you have not returned to work or need benefits reactivated. Provide reasons and relevant dates as outlined in the form.
8. Sign and date the Employee Certification/Authorization section, confirming that all information provided is accurate and that you authorize medical information relevant to your claim to be shared.
9. Once you have filled out the Employee Section, submit it along with any supporting medical documentation to your Human Resources department as soon as possible.
10. For the Employer Section on page 2, ensure that your employer completes all required fields, including your name, BWC claim number, and the employer’s details. This must be done within five working days of receiving your completed employee section.
11. Finally, the employer must sign and date the report, as well as complete an ADM 4741 Calendar of Wages. Fax all documents to the designated Third Party Administrator.

Complete your forms online to ensure a timely processing of your benefits request!