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Get OH BWC 1174 2008-2024

Lieu of temporary total or living maintenance compensation. Regular (full) salary/wages includes any benefits which the employee would normally be entitled to if the employee was working. This form must be signed by the employee and the employer. Fax or mail this completed agreement to your local BWC service office. Employee name Employer name Claim number Policy number Employer telephone number On the ________ day of _________________ , ______ , ____________________________ , the employe.

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