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This document is an application form for obtaining a Representative Identification Number (RIN) from the Bureau of Workers\' Compensation (BWC) in Ohio. It outlines the necessary information required from individuals or organizations, such as attorneys, union representatives, and firms, to apply for representation in individual claims. The form includes options for different types of applicants, contact information, and signature requirements.

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How to fill out bwc-6104

01

Obtain a blank BWC-6104 form from the relevant authority.

02

Fill in your personal information, including name, address, and contact details.

03

Provide the date of the incident or claim related to the form.

04

Clearly describe the nature of the claim, including any pertinent details.

05

List any associated medical providers or witnesses, if applicable.

06

Review all information for accuracy and completeness.

07

Sign and date the form at the designated area.

08

Submit the form according to the instructions provided, whether by mail or electronically.

Who needs bwc-6104?

01

Individuals who have sustained a work-related injury or illness.

02

Employees seeking compensation benefits under workers' compensation programs.

03

Employers filing claims on behalf of their injured workers.

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What is bwc-6104?

BWC-6104 is a form used for reporting specific information related to workers' compensation claims and benefits in Ohio.

Who is required to file bwc-6104?

Employers who have employee workers' compensation claims must file the BWC-6104 form.

How to fill out bwc-6104?

To fill out BWC-6104, gather all necessary claim and employee information, complete the form accurately, and submit it to the appropriate workers' compensation authority.

What is the purpose of bwc-6104?

The purpose of BWC-6104 is to provide a structured way to report detailed information about workers' compensation claims for compliance and record-keeping.

What information must be reported on bwc-6104?

The BWC-6104 requires reporting of claim numbers, employee details, accident dates, and information regarding the benefits being claimed.

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