Employer/Employee Agreement to Select Ohio
as the State of Exclusive Remedy
for Workers’ Compensation Claims
Please read the instructions below before completing this form.
An employee who enters into an employment contract outside of Ohio may work in another state some or all of the time. This leads to the possibility that
Ohio’s workers’ compensation laws may conflict with those of the other state. In these cases, Ohio law allows employers and employees to choose workers’
compensation coverage from Ohio or from the other state.
• Use this form to choose Ohio coverage. By signing this form, both the employee and employer agree to be bound exclusively
by the workers’ compensation laws of Ohio.
• Use form C-112 to choose coverage from a state other than Ohio. By signing that form, both the employee and employer agree to
be bound exclusively by the workers’ compensation laws of the other state. You may get form C-112 from ohiobwc.com.
Important notes: (1) Neither form C-110 n