Ohio Form C-110 is the Notice of Appeal used to challenge a workers’ compensation order issued by the Ohio Bureau of Workers’ Compensation (BWC) or a District Hearing Officer (DHO) of the Industrial Commission of Ohio (IC). The form is filed under Ohio Revised Code 4123.511 by injured workers, employers, or their representatives within 14 days of receiving the order they want to appeal.
If you miss the 14-day window, the order becomes final and you lose the right to a hearing on that issue. The IC processes more than 140,000 hearing requests every year, and a measurable share are dismissed for late filing or missing claim numbers, which makes careful completion of C-110 critical.
Here is what you will learn in this guide:
- 📄 What Form C-110 is, who must file it, and which orders it can appeal
- 🗂️ The exact documents, claim data, and IDs you need before you start
- ✍️ A line-by-line walkthrough of every field, box, and signature block on C-110
- 👥 Three full-scenario examples showing what real filers enter on the form
- ⚖️ Filing channels, deadlines, post-filing steps, and the most common mistakes that cause dismissal
What Form C-110 Is and Who Must File It
Ohio Form C-110 is the Notice of Appeal that moves a workers’ compensation dispute from one level of decision-making to the next inside the Industrial Commission of Ohio. The form is the procedural key that unlocks a hearing in front of a District Hearing Officer or a Staff Hearing Officer, depending on which order is being appealed. Without a timely C-110 on file, the order it targets becomes the final word on the issue.
The form is used by three main groups of filers. Injured workers file C-110 when the BWC denies a claim, denies a benefit such as temporary total disability, or grants less than what was requested. Employers file C-110 when the BWC allows a claim or adds a new condition the employer believes is not work-related. Authorized representatives, including attorneys and union reps, file C-110 on behalf of either party under Ohio Administrative Code 4121-3-08.
C-110 can appeal several order types: BWC orders on claim allowance, additional allowance, compensation, or medical treatment; DHO orders issued after the first IC hearing; and certain self-insured employer determinations. It does not appeal Staff Hearing Officer orders to court, that step uses a separate notice under ORC 4123.512. Knowing which order you have in hand is the first step to using the right form.
The statute behind C-110 is ORC 4123.511, which sets the 14-day deadline and the chain of appeal. The plain-English rule is simple: every order has 14 days, and every appeal needs a written notice. The consequence of ignoring this rule is permanent loss of appeal rights on the issue. A common misconception is that calling the BWC or asking a question is “appealing.” It is not. Only a written, signed, timely C-110 (or its online equivalent) preserves your rights.
Before You Start: Documents and Information You Need
Before you open the form, gather everything you will need to fill it out correctly the first time. The IC will not chase you for missing information, it will simply schedule the hearing on what you submitted, which can hurt your case.
Use this pre-filing checklist:
- The order being appealed. You must list the order date and order number exactly. If the order is missing, the IC may not know which decision you are challenging, and your appeal can be returned.
- The seven-digit claim number. The number appears on every BWC and IC document. A wrong claim number routes your appeal into the wrong file and can delay the hearing by weeks.
- The injured worker’s full legal name. Names must match the BWC claim record. A nickname or married name that is not in the file can cause a clerical mismatch.
- The injured worker’s date of injury. This anchors the claim and helps the IC verify you are appealing the correct file.
- The employer’s legal name and BWC policy number. Both parties get notice of every appeal under ORC 4123.511(B), so the IC needs the employer’s identity.
- A current mailing address, phone, and email. The IC mails hearing notices, and a wrong address means a missed hearing.
- Representation information. If a lawyer or union rep is filing for you, you need their name, IC representative ID, and a signed R-1 authorization on file.
- A short, written reason for the appeal. C-110 asks you to state what you are appealing. A clear sentence (“I appeal the denial of temporary total disability from 03/01/2026 forward”) protects your issues.
- A copy of the order itself. Attaching the order helps the IC index your appeal correctly.
- Supporting medical or wage evidence (optional at filing). You can submit evidence later, but having it ready avoids a continuance.
Missing any one of these can slow your case. The IC schedules hearings about 45 days out from the appeal date, and a defective C-110 can push that timeline back by another 30 to 60 days.
Where to Get the Form and How to Access It
The official Form C-110 is published by the Industrial Commission of Ohio Forms Library. The current revision date is printed in the lower corner of the PDF, and you should always confirm you are using the most recent version before filing. Older revisions may omit fields the IC now requires, such as the email contact line added in recent updates.
You can access C-110 through four channels. The first is the IC website, where you can download a fillable PDF. The second is the IC online portal, accessible through the IC eFile system, which lets you submit the same information electronically without printing the form. The third is any IC district office, where paper copies are available at the front desk in cities like Columbus, Cleveland, Cincinnati, Toledo, Akron, Dayton, and Youngstown. The fourth is the BWC customer service line at 1-800-644-6292, which can mail a copy.
If you cannot read English, the IC provides interpreter services at no cost, and forms can be completed with the help of an interpreter at any district office. If you have a disability that affects reading or writing, the IC will assist under the Americans with Disabilities Act.
A common misconception is that C-110 must be notarized. It does not. A signature under penalty of perjury is enough under OAC 4121-3-09. Another misconception is that you must use the PDF, you do not, the eFile portal is fully equivalent.
Step-by-Step: How to Fill Out Ohio Form C-110 Line by Line
The form is short, but every box matters. Use one H3 per field below and follow the same six-element pattern: what the field asks, how to answer it, an example entry, a nuance, a mistake plus its consequence, and a misconception.
Box 1: Claim Number
This box asks for the seven-digit number the BWC assigned to the injury claim. Write the number exactly as it appears on the order, with the hyphen if the order shows one (for example, 12-345678). Do not invent leading zeros and do not use the policy number in this box.
Maria Lopez writes 23-456789 in Box 1, copying it from the top of the BWC order denying her TTD.
A common nuance: if the worker has more than one claim, you must file a separate C-110 for each claim number. One form cannot appeal orders in two different claims, even if the issues feel related.
The most common mistake is transposing two digits. The consequence is that the IC dockets your appeal into the wrong file or rejects it as unmatched, and your 14-day clock can run out before you discover the error. A misconception is that the BWC policy number and the claim number are the same, they are not, the policy number belongs to the employer.
Box 2: Injured Worker’s Name
This field asks for the full legal name of the injured worker, even when the employer is the one filing the appeal. Write the name in First Middle Last order, exactly as it appears on the BWC claim file. Avoid nicknames, suffixes only when they are part of the legal name, and any abbreviation.
Carlos A. Mendez enters his name on a self-filed appeal, matching the spelling on his Social Security card.
A nuance arises when the worker has changed names, by marriage or court order. Use the name currently on the claim, then note the prior name in the comments section to keep the file linked.
The common mistake is writing the employer’s name in this box when the employer is appealing. The consequence is that the IC may misroute the appeal or treat it as defective. A misconception is that this box should hold the filer’s name, it always holds the injured worker’s name.
Box 3: Date of Injury
The field asks for the date the work injury or occupational disease occurred or was diagnosed. Use the MM/DD/YYYY format with slashes, not dashes. The date must match the date of injury on the original BWC order.
Janet Reilly enters 11/04/2025 as the date she slipped on a loading dock.
For occupational disease claims, use the date of diagnosis or last exposure, whichever the BWC used to allow or deny the claim. For repetitive trauma, use the date the BWC adopted in the order.
The common mistake is using the date the order was issued instead of the injury date. The consequence is a mismatch with the claim file and a delayed hearing. A misconception is that approximate dates are acceptable, the IC requires the exact date already in the file.
Box 4: Employer’s Name and Policy Number
This field asks for the legal name of the employer at the time of injury and the BWC policy number. Write the employer name as it appears on the BWC certificate of coverage, then the policy number in the format printed on the order (often a seven- or eight-digit number).
Marcus Hill writes Northside Logistics LLC, Policy 1234567-0 on his employer-filed C-110.
A nuance: for self-insured employers, write “Self-Insured” after the name and use the SI employer number assigned by the BWC instead of a policy number.
A common mistake is using the trade name (DBA) instead of the legal entity. The consequence is that notice may not reach the right corporate address. A misconception is that the policy number is optional, it is not, the IC uses it to confirm coverage.
Box 5: Order Being Appealed (Date and Number)
This field asks for the date of the order you are appealing and, if shown, the order number. Copy both directly from the order document, using MM/DD/YYYY for the date.
Aisha Brown writes Order dated 04/15/2026, Order No. 26-04-1234 on her appeal of a DHO order.
A nuance arises when more than one order issued on the same date. List both order numbers in this box, separated by a comma, so the IC can pull both for the hearing.
The common mistake is leaving this box blank because the filer does not see an order number. The consequence is that the IC cannot identify which decision is being challenged. A misconception is that the mailing date on the envelope counts, it does not, the order date printed on the order itself controls.
Box 6: Reason(s) for Appeal
This box asks why you disagree with the order. Write a short, specific sentence that names the issue and the relief you want. You do not need legal language, but you should name the benefit, the period, or the condition in dispute.
“I appeal the denial of temporary total disability compensation from 03/01/2026 through the present and request allowance of TTD,” writes Maria Lopez.
A nuance is that you are not locked into the wording forever, you can expand the issues at the hearing, but a clear statement helps the hearing officer prepare and avoids surprise objections.
The common mistake is writing “I disagree” with no detail. The consequence is a vague record that can hurt you on further appeal. A misconception is that you must prove your case in this box, you do not, you only need to identify the dispute.
Box 7: Filer’s Role
This field asks whether you are filing as the injured worker, employer, or representative. Check exactly one box. If a representative is filing, the worker or employer should still be identified in their own boxes.
Attorney Lisa Park checks “Representative” on a C-110 she files for her client.
A nuance: if you are both an employer and a representative (for example, an HR director who is also the company’s authorized rep), check Employer, because the company is the appealing party.
The common mistake is checking two boxes. The consequence is an unclear filing that the IC may return for clarification. A misconception is that this box decides who attends the hearing, it does not, all parties receive notice regardless.
Box 8: Mailing Address, Phone, and Email
This block asks for the filer’s current contact information. Use a street address or P.O. Box where mail is reliably received, a phone number with area code, and an email you check often.
Carlos Mendez writes 482 Maple St., Apt 3B, Dayton, OH 45402, (937) 555-0142, carlos.mendez@email.com.
A nuance applies when the filer moves during the appeal. File a written change of address with the IC right away under OAC 4121-3-04, or you risk missing a hearing notice.
The common mistake is using a workplace address that the filer no longer uses. The consequence is missed mail and a missed hearing, which can dismiss the appeal. A misconception is that an email address replaces a mailing address, it does not, the IC still mails official notices.
Box 9: Representative Information
This field asks for the name, address, phone, email, and IC representative number of the attorney or non-attorney representative, if any. Leave it blank if you are filing pro se.
Lisa Park, Esq., IC Rep #R-12345, Park & Associates, 100 E. Broad St., Columbus, OH 43215, (614) 555-0199, lpark@parklaw.com.
A nuance: a R-1 authorization must be on file, otherwise the IC may not communicate with the rep. File the R-1 with or before the C-110 to avoid delays.
The common mistake is listing a paralegal or assistant as the rep. The consequence is that the IC will not recognize the contact for case decisions. A misconception is that any lawyer can sign without an IC rep number, attorneys still need to be properly identified for the file.
Box 10: Signature and Date
This block asks for the filer’s handwritten or electronic signature and the date signed. The signature is made under the penalty of perjury under ORC 2921.11.
Janet Reilly signs in cursive and writes 04/29/2026 as the date.
A nuance is that an electronic signature through the IC eFile portal is treated the same as a wet-ink signature. If the worker cannot sign because of a medical condition, a representative may sign with a power of attorney attached.
The common mistake is leaving the date blank or backdating the signature. The consequence is a defective filing or a fraud referral. A misconception is that a typed name in a Word file counts as a signature, it does not, you must either sign on paper or use the IC’s eFile system.
Three Filled-Out Examples Using Real Scenarios
Below are three full-walkthrough scenarios. Each follows one named filer through Form C-110 from start to finish.
Scenario 1: Maria Lopez Appeals a TTD Denial
Maria is a 38-year-old warehouse picker. The BWC denied her TTD compensation after a back strain.
| Form Section | What Maria Enters |
|---|---|
| Box 1: Claim Number | 23-456789 |
| Box 2: Injured Worker | Maria E. Lopez |
| Box 3: Date of Injury | 02/14/2026 |
| Box 4: Employer / Policy | Riverbend Distribution Inc., Policy 9876543-0 |
| Box 5: Order Appealed | Order dated 04/10/2026, No. 26-04-0987 |
| Box 6: Reason for Appeal | “I appeal the denial of TTD from 02/15/2026 to present and request allowance.” |
| Box 7: Filer’s Role | Injured Worker |
| Box 8: Contact | 55 Pine Ave, Toledo, OH 43604, (419) 555-0177, mlopez@email.com |
| Box 10: Signature & Date | Maria E. Lopez, 04/22/2026 |
Scenario 2: Northside Logistics Appeals an Additional Allowance
Northside Logistics, a private employer, contests a DHO order adding “L5-S1 disc herniation” to a claim it believes is not work-related.
| Form Section | What Northside Enters |
|---|---|
| Box 1: Claim Number | 22-112233 |
| Box 2: Injured Worker | Marcus T. Hill |
| Box 3: Date of Injury | 09/03/2025 |
| Box 4: Employer / Policy | Northside Logistics LLC, Policy 1234567-0 |
| Box 5: Order Appealed | DHO Order dated 05/05/2026, No. 26-05-2211 |
| Box 6: Reason for Appeal | “Employer appeals the additional allowance of L5-S1 disc herniation as not causally related.” |
| Box 7: Filer’s Role | Employer |
| Box 8: Contact | 1200 Industrial Pkwy, Cleveland, OH 44114, (216) 555-0123, hr@northsidelog.com |
| Box 9: Representative | Lisa Park, Esq., IC Rep #R-12345 |
| Box 10: Signature & Date | Lisa Park, Esq., 05/12/2026 |
Scenario 3: Aisha Brown Appeals a Denied Claim Allowance
Aisha is a home health aide whose claim for a wrist injury was denied at the BWC level.
| Form Section | What Aisha Enters |
|---|---|
| Box 1: Claim Number | 26-778899 |
| Box 2: Injured Worker | Aisha N. Brown |
| Box 3: Date of Injury | 03/22/2026 |
| Box 4: Employer / Policy | Sunrise Home Care LLC, Policy 5566778-0 |
| Box 5: Order Appealed | BWC Order dated 04/18/2026, No. 26-04-3344 |
| Box 6: Reason for Appeal | “I appeal the denial of claim allowance for right wrist sprain and request allowance.” |
| Box 7: Filer’s Role | Injured Worker |
| Box 8: Contact | 14 Elm St, Cincinnati, OH 45202, (513) 555-0144, aisha.brown@email.com |
| Box 9: Representative | Blank (pro se) |
| Box 10: Signature & Date | Aisha N. Brown, 04/25/2026 |
These three filers cover the most frequent C-110 fact patterns and show how the same form serves very different disputes.
How to File the Completed Form
The IC accepts C-110 through four filing channels, and the date the IC receives the form is what counts for the 14-day deadline under ORC 4123.511(C).
Online (IC eFile portal). Submit through the IC eFile system. There is no fee. Payment methods are not applicable. Processing begins the same business day, and you receive an electronic confirmation number that serves as proof of filing. Save the confirmation email and the PDF receipt.
By mail. Send to the Industrial Commission of Ohio, 30 W. Spring St., Columbus, OH 43215-2233. There is no fee. Use certified mail with return receipt requested so you have proof of mailing and delivery. Allow 7 to 10 business days for the IC to docket the appeal.
In person. Drop the form at any IC district office during business hours, generally 8:00 a.m. to 5:00 p.m., Monday through Friday. There is no fee. Ask the front desk to date-stamp your copy and keep that copy as proof of filing. Same-day docketing is typical.
By fax. Send to the fax number listed on the IC’s contact page for the relevant district office. There is no fee. Keep the fax confirmation sheet, including the time stamp, as your proof. Faxes received after 5:00 p.m. may be docketed the next business day.
The accepted proof of filing in any channel is a date-stamped copy, a certified mail receipt, an eFile confirmation number, or a fax confirmation sheet. Without proof, a late argument from the other side can be hard to rebut.
What Happens After You File
Once the IC dockets your C-110, the case moves into the hearing pipeline under OAC 4121-3-09. Within about 14 days, the IC mails a Notice of Hearing with the date, time, location, and hearing officer level. Hearings are usually held within 45 days of the appeal at the district office closest to the injured worker.
Both parties have the right to attend, present evidence, call witnesses, and be represented. After the hearing, the hearing officer issues an order, generally within 7 days. If you disagree with that order, you have another 14 days to appeal again, this time to the next level (DHO to SHO, or SHO to court under ORC 4123.512).
A common misconception is that filing C-110 freezes payments already being made. It does not in most situations, payments tied to a prior allowed condition continue unless a new order changes them. Another misconception is that you can submit new evidence at any time. You can, but late evidence may force a continuance and delay your hearing by weeks.
The consequence of skipping the hearing is dismissal of the appeal and finality of the order you challenged. Showing up matters more than any single piece of paper you file.
Mistakes to Avoid When Filling Out the Form
These are the errors the IC sees most often. Each one has a real consequence.
- Filing after 14 days. Your appeal will be dismissed as untimely under ORC 4123.511.
- Wrong claim number. Your appeal lands in the wrong file or no file, delaying the hearing.
- Blank order date. The IC cannot identify which decision is being appealed, leading to a return for correction.
- Vague reason for appeal. A simple “I disagree” gives you no record to build on for further appeals.
- Using a nickname for the injured worker. A name mismatch can stall docketing.
- Skipping the signature. An unsigned C-110 is not a valid appeal and the deadline keeps running.
- Backdating the signature. This can trigger a fraud referral under ORC 2921.13.
- Listing a paralegal as the representative. The IC will not recognize the contact for case decisions.
- Faxing without keeping the confirmation. You lose proof of timely filing if the other side challenges the date.
- Using the wrong form. Appeals to court use a different notice, not C-110, and filing C-110 in court is ineffective.
- Filing one C-110 for two claims. Each claim needs its own form; combined filings get split or rejected.
- Wrong employer name. Notices may not reach the right party, raising due-process problems at the hearing.
Each mistake on this list has cost real claimants real benefits. Treat the form like a legal pleading, because in Ohio it is one.
Do’s and Don’ts
A short list of habits that protect your appeal.
Do’s
- Do copy the claim number digit-for-digit from the order, because a mismatch causes routing errors.
- Do use MM/DD/YYYY on every date field, because the IC’s docket system expects that format.
- Do state the specific benefit or condition in the reason box, because clarity preserves issues for later.
- Do keep a stamped or electronic copy of every C-110 you file, because proof of filing is your safety net.
- Do file early in the 14-day window, because last-minute filings leave no margin for fax errors or mail delays.
- Do update your address in writing if you move, because hearing notices go to the address on file.
Don’ts
- Don’t sign a blank form for someone else, because that can be perjury under ORC 2921.11.
- Don’t rely on a phone call to “appeal,” because only a written, signed C-110 (or eFile equivalent) counts.
- Don’t combine multiple claims on one form, because the IC cannot split them cleanly.
- Don’t assume the BWC will forward your appeal, because the IC is the receiving body for C-110.
- Don’t leave the representative box half-filled, because incomplete rep info delays communication.
- Don’t ignore the hearing notice once it arrives, because skipping the hearing dismisses the appeal.
Pros and Cons of Filing on Your Own vs. With Help
Many filers can complete C-110 themselves, but a representative can add value when the issues are complex.
Pros of filing pro se
- Free. No attorney fee, which matters when income is interrupted.
- Fast. You can file the same day you receive the order.
- Direct. You speak for yourself at the hearing without a middle layer.
- Simple form. C-110 is one page and uses plain prompts.
- Full control. You decide what to write in the reason for appeal.
Cons of filing pro se
- No legal coaching. You may miss arguments a lawyer would raise.
- Evidence gaps. Pro se filers often skip medical reports the IC weighs heavily.
- Procedural traps. The 14-day deadline and notice rules trip up many first-time filers.
- Stress. Hearings are recorded and formal, which can rattle unrepresented filers.
- Limited appeal strategy. Without a lawyer, the next level of appeal can feel overwhelming.
A balanced view: simple denials of allowance with strong medical proof are often handled pro se, while contested additional allowances, occupational disease claims, and PPD disputes typically benefit from a licensed Ohio attorney.
Comparing C-110 to Related IC Notices
Filers sometimes confuse C-110 with other appeal documents. The differences below come straight from the IC forms library.
| Notice | Purpose |
|---|---|
| C-110 | Appeal a BWC or DHO order to the next IC level under ORC 4123.511. |
| IC-12 | Request reconsideration of an SHO order on jurisdictional grounds. |
| Court Notice of Appeal | Appeal an SHO order to common pleas court under ORC 4123.512. |
| R-1 | Authorize a representative to act on a claim, filed alongside C-110 when applicable. |
Using the wrong notice at the wrong stage is one of the most expensive mistakes a filer can make.
FAQs
Is Form C-110 the same as a court appeal?
No. C-110 stays inside the Industrial Commission. Court appeals of SHO orders use a separate notice under ORC 4123.512 and must be filed with the common pleas court.
Do I have to pay a fee to file C-110?
No. The Industrial Commission does not charge a filing fee for C-110, regardless of channel.
Can I file C-110 by email?
No. The IC accepts C-110 by mail, fax, in person, or through the eFile portal, but not by ordinary email.
Do I write my maiden name or married name in Box 2?
Yes, use whichever name is on the BWC claim file. Note the other name in the comments section so the IC can link the records.
Is the date in Box 3 the date the order issued?
No. Box 3 is the date of injury, not the date of the order. The order date goes in Box 5.
Can one C-110 appeal two different orders?
No, unless both orders share the same claim number and were issued the same day. Otherwise, file a separate C-110 for each.
Do I have to attach the order I am appealing?
No, but it helps. The IC can find the order from Box 1 and Box 5, but attaching a copy speeds docketing.
Can my employer see what I wrote in Box 6?
Yes. Both parties get a copy of the appeal under ORC 4123.511(B), so write professionally.
Will filing C-110 stop my benefits?
No, not by itself. Benefits already being paid on allowed conditions continue until a new order changes them.
Can I add issues at the hearing that I did not list in Box 6?
Yes, with the hearing officer’s permission, but a clear Box 6 protects your record on further appeal.
Is a typed name a valid signature on C-110?
No, unless it is submitted through the IC eFile system, which treats electronic signatures as valid.
Do I need a lawyer to file C-110?
No. Many injured workers file pro se. A lawyer is helpful for complex medical disputes or when the next appeal goes to court.
What if I miss the 14-day deadline?
No late C-110 will be heard absent extraordinary circumstances. The order becomes final and the issue is closed.
Can I withdraw a C-110 after filing?
Yes. File a written withdrawal with the IC before the hearing and the appeal is dismissed at your request.
Related reading
- How to Fill Out Ohio Form C-1 (w/Examples) + FAQs
- How to Fill Out Ohio Form C-3 (w/Examples) + FAQs
- How to Fill Out the Ohio Industrial Commission Notice of Appeal (IC-12) + FAQs
- How to Fill Out the Ohio Industrial Commission (IC-88) Application for Reconsideration + FAQs
- How to Fill Out North Carolina Industrial Commission Form 33 + FAQs
- How to Fill Out the Colorado WC Application for Hearing (w/ Examples) + FAQs
- How to Fill Out California WCAB DWC-AD 1 (w/Examples) + FAQs