Application for Exemption from Ohio Workers' Coverage and Waiver of Benefits You must complete all sections of this form before submitting it to the Ohio Bureau of Workers' Compensation, Policy Processing, 22nd Floor, 30 W. Spring St., Columbus, OH 43215-2256. You may submit federal forms 4029 and 4361 with this application if approved by the Internal Revenue Service. CAUTION This form does not grant you the right to an exemption from any other Ohio, federal or local tax liability. The employer is applying for exemption from paying BWC compensation premiums or assessments in respect to each employee completing Section III of this form.This includes self-insuring employers paying compensation and benefits directly. This exemption does not relieve the employer from the obligation to pay the applicable minimum administrative charge. The employer certifies he or she has informed each employee completing Section III of this form that he or she is waiving the right to receive workers' compensation benefits. In addition, the employer and employee must complete and have notarized the attached affidavits and return them with the U-3E application. If there are multiple employees, additional copies may be made. The employer agrees to notify BWC within 30 days of any occurrence that results in the employer no longer being designated as a member of the religious group described below, or that the employer no longer follows the established teachings of this group. From that date forward, the employer will be responsible for all premiums and assessments. This includes self-insuring employers paying compensation and benefits directly. Section I ­ Employer (Please print or type) Company name Employer name Street address or P.O. Box number Employer signature Federal ID number Email address City, State, ZIP code Policy number Telephone number ( ) Date Section II ­ Religious group (Please print or type) Religious group name Street address or P.O. Box number City, state, ZIP code Group official name Email address Telephone number ( ) I certify ________________________________________________ is a member of the above named religious group and that the Employer name religious group has been in existence at all times since Dec. 31, 1950. As members of the group and followers of its established teachings, we are conscientiously opposed to accepting benefits from any private or public insurance that makes payments in the event of death, disability, impairment, old age or retirement, or makes payments toward the cost of, or provides services in connection with the payment of medical services. Bishop signature Date BWC use only Exemption approved Authorized BWC representative signature Exemption disapproved Date BWC-7614 (June 5, 2014) U-3E page 1 Section III on page 2 American LegalNet, Inc. www.FormsWorkFlow.com Application for Exemption from Ohio Workers' Coverage and Waiver of Benefits CAUTION This form does not grant you the right to an exemption from any other Ohio tax liability, federal tax liability or local tax liability. The employee agrees to notify BWC within 30 days of any occurrence that results in the employee no longer being designated as a member of the religious group described below, or that the employee no longer follows the established teachings of this group. From that date forward, the employer will be responsible for all premiums and assessments. This includes self-insuring employers paying compensation and benefits directly. Section III ­ Employee (Please print or type) Employee name Street address or P.O. Box number City, State, ZIP code Company name Employee signature Policy number Date Email address Social Security or 4029 number Telephone number ( ) I certify __________________________________________ is a member of the above named religious group and is Employee name in good standing and follows the tenets of this religion. Bishop signature Date By my signature, I certify I have the authority to execute this document, and that the facts set forth on this document are true and correct to the best of my knowledge and belief. I am aware that any person who does not secure or maintain workers' compensation coverage and pay all appropriate premiums in accordance with Ohio laws, or misrepresents, conceals facts, or makes false statements to obtain coverage may be subject to civil, criminal and/or administrative penalties. BWC use only Exemption approved Authorized BWC representative signature Exemption disapproved Date BWC-7614 (June 5, 2014) U-3E page 2 American LegalNet, Inc. www.FormsWorkFlow.com Application for Exemption from Ohio Workers' Coverage and Waiver of Benefits Affidavit of Employer pursuant to R.C. 4123.15 AFFIDAVIT OF ______________________________________________________________________________ (print name) I, ____________________________________________, swear or affirm: 1. That I am the Employer/Owner/Corporate Officer of ________________________________, (business name) located at _______________________________________________________________ (business address). 2. I am a member of a recognized religious sect or division of a recognized religious sect, ___________________________________________________(name of religious sect) and am an adherent of established tenets or teachings of that sect and am conscientiously opposed to benefits to employers and employees received from any public or private insurance that makes payments in the event of injury, death, disability, impairment, old age, or retirement or makes payments toward the cost of, or provides services in connection with the payment for, related medical services, including the benefits from any insurance system established by the "Social Security Act, 42 U.S.C.A. 301 , et seq. " Further affiant saith not. I SWEAR OR AFFIRM THAT THE ABOVE AND FOREGOING REPRESENTATIONS ARE TRUE AND CORRECT TO THE BEST OF MY INFORMATION, KNOWLEDGE, AND BELIEF . Date: _______________________________ Name: _______________________________________________________ Printed name: ________________________________________________ STATE OF _______________________________________________________________________________________________ COUNTY OF _____________________________________________________________________________________________ I, the undersigned Notary Public, do hereby affirm that ________________________________________, personally appeared before me on the _____ day of ____________, 20_____, and signed the above Affida