Finance Office

Diocese of Cleveland

Workers’ Compensation – Claim Procedures

What To Do If You Have A Claim

In the event of an injury, necessary forms which should be in your Workers’ Compensation binder should be filled out. These same forms are also below and can be printed out.

BWC First Report of Injury

Please complete the entire injured worker section ONLY (top half of page). If possible the employee should take the completed form to the medical provider.

Incident Report

This form should be filled out as completely as possible including any witness statements.

Medical Release Forms

This form should be signed and dated by the employee.

Wage Statement Forms

These need only be filled out if the employee will miss more than 7 days from the date of injury.

Offer of Return to Work Light Duty

Injured worker is released to work light duty by their physician of record, and their employer is able to accommodate such restrictions. This offer must be given in writing.

The injured worker can be treated at a facility of their choice, and in any life threatening situation the closest emergency facility should be used.

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