Employer/Employee Agreement to Select a State Other Than Ohio as the State of Exclusive Remedy for Workers' Compensation Claims Please read 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 (C-112) to choose coverage from a state other than Ohio. By signing this form, both the employee and employer agree to be bound exclusively by the workers' compensation laws of the other state. · Use form C-110 to choose Ohio coverage. By signing that form, both the employee and employer agree to be bound exclusively by the workers' compensation laws of Ohio. You may get form C-110 from www.bwc.ohio.gov. Important notes: (1) Neither form C-112 nor C-110 can create jurisdiction where none exists. The forms merely clarify which state's laws will apply in the event of a conflict between states having jurisdiction over an employer and employee. (2) Although BWC honors a valid C-112 in Ohio, the laws of another state might not recognize the terms of the agreement. Consult the workers' compensation agency in the other state or private counsel to verify the validity of this agreement outside Ohio. Instructions for completing the form · · · · Use a separate form for each employee. Only one employee should sign the form. It is not for use by multiple employees. The employer should keep a signed copy for company records and provide a copy to the employee. To be legally valid, the employer must submit the agreement to BWC within 10 days of signing this agreement. Submit completed agreements to BWC's policy processing via fax at (614) 621-1435 or by mail to: BWC Policy Processing Dept., 30 W. Spring St., 22nd floor, Columbus, OH 43215. · The employer must attach a certificate of coverage from the other state(s) to this agreement. · The employer must maintain an active Ohio workers' compensation policy for the agreement to be valid. · The employer will not report the payroll of any employee covered by a valid C-112 to BWC. The parties to this agreement represent to BWC that there is a possibility of a conflict between the workers' compensation laws of Ohio and those of another state, because the employee entered into the contract of employment and will perform all or some of the work in a state or states other than Ohio. and not in Ohio. The state(s) in which the employee The employee entered into the contract of employment in will work is (are) . Under Ohio Revised Code Section 4123.54, the employer and employee agree to be bound exclusively by the workers' compensation laws of (not Ohio) as the state of coverage and have attached a certificate of coverage. Regardless of where a work-related injury or death occurs or where an employee contracts an occupational disease, the workers' compensation laws of that state and not the laws of Ohio will govern the rights of the employee and his or her dependents. The employer has complied with the workers' compensation laws of the above state, paid premiums, and maintains active coverage. This agreement shall remain in effect until the parties terminate or modify it by filing a new agreement. Employee approval Employee's first name/middle initial/last name (please print): Employee's address: City: Employee's signature: Phone number: ( ) Fax number: ( ) E-mail: State: ZIP code: Date: - - Employer approval Name of employer: Employer's address: City: Ohio business location address: City: Employer's signature*: Phone number: ( ) Fax number: ( ) State: Title: E-mail: ZIP code: Date: State: ZIP code: Employer's BWC policy number: - - *An owner, partner or officer must sign this agreement. BWC-1235 (Rev. 4/27/2009) C-112 American LegalNet, Inc. www.FormsWorkFlow.com