Application for Industry-Specific Safety Program Instructions Complete all fields in this application. BWC cannot process incomplete applications. An officer, partner or owner must sign this application. You may submit the completed form in one of three ways listed below. Online ­ www.bwc.ohio.gov Fax ­ 614-621-1405 Mail ­ Attention: Industry-Specific Safety Program Ohio Bureau of Workers' Compensation 30 W. Spring St., 22ND Floor Columbus, OH 43215-2256 Important reminder For BWC to process the Industry-Specific Safety Program application, you must complete the Safety Management Self-Assessment (SH-26) no later than 30 days after you start the program. The deadline for application receipt is the last business day in May for the July 1 to June 30 program period for private employers and the last business day in November for the Jan. 1 to Dec. 31 program period for public taxing. Employer information Name of employer and DBA Address City Employer contact for Industry-Specific Safety Program Email address for Industry-Specific Safety Program contact State Phone number Fax number ZIP code Federal tax ID number BWC policy number Note To receive the industry-specific safety discount, private employers commit to completing the action(s) below during the July 1 to June 30 program year; the time frame for public employers is the Jan. 1 to Dec. 31 program year. Participate in loss-prevention activities, based on payroll reported in the previous policy year as noted below. o Industry-specific safety classes offered by BWC's Division of Safety & Hygiene (DSH) o On-site safety consulting by DSH experts o BWC's annual Ohio Safety Congress & Expo The payroll reported by the employer in the previous policy year will determine whether an employer must complete one, two or three, lossprevention activities based on the following: Less than or equal to $100,000 any one loss-prevention activity; Greater than $100,000 and up to $300,000 any two loss-prevention activities; Greater than $300,000 any three loss-prevention activities. While participating in the Industry-Specific Safety Program, you should verify other BWC programs that are compatible with it. You may participate in more than one BWC program. However, only certain programs may be combined in the discount calculation. Please reference the compatibility chart found in Ohio Administrative Code 4123-17-74. Owner/partner/officer statement of agreement I hereby certify that my company is applying for the Industry-Specific Safety Program pursuant to OAC 4123-17-56.3. I also certify that my company will meet, at minimum, the requirements associated with the program. I understand that if my company does not meet the requirements, I agree to repay any benefits received. Also, I certify this information is accurate and, if not, may subject the employer applicant and myself to civil and criminal penalties. Name of designated representative certifying intent to comply and willingness to pay back bonus for non-compliance. Owner/partner; officer name Title Signature Date BWC-6627 (Rev. Feb. 12, 2015) SH-28 American LegalNet, Inc. www.FormsWorkFlow.com