BWC will reject incomplete applications Instructions · · · · · · · · · · Application for Retrospective-Rating Plan for Public Employers Anowner/partner/officermustsigntheapplication. Youmustfileanewapplicationforeachpolicyyear. OnceBWCapprovestheapplication,theplanwillremaininforcefortheentirepolicyyear. Employers must file the application and all other required documentation by the last business day of July for the policy year beginning Jan 1. BWC charges an annual minimum premium based on a factor of the estimated policy year experience-rated/base-rated premium even if there are no losses. BWCoffersTierIandTierIIplans.TierIisavailabletoemployersmeetingallBWCrequirementsincludingfinancialstrength.TierIIisavailableto employers who do not meet Tier I requirements, but do meet other requirements as specified by BWC. Applicants must submit audited financial statements (according to GAAP standards) for the last five years, which includes a balance sheet, income statement and a retained earnings statement. Publicemployertaxingdistrictsmustattachtheircurrentbondrating. Application for any retrospective rating plan is optional; but if application is made, all operations of the employment entity are subject to retrospective rating. Directquestionsconcerningthisapplicationtotheemployerprograms'retrospectiveratingunitat614-466-6773. Youmaysubmitacompletedapplicationinoneofthreeways: Online ­ www.bwc.ohio.gov; Fax­614-621-1405; Mail­BWC,EmployerPrograms,RetrospectiveRatingUnit,22ndFloor,30W.SpringSt.,Columbus,OH43215-2256. While participating in the Retrospective-Rating 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. Federal ID number Employer name Address City Contact name Contact title State ZIP code Telephone number Email address Policy number ( ( ) ) Fax number Retrospective-rating plan parameter selections: The employer must select the retrospective-rating plan parameters listed below. BWC will determine the minimum and maximum premium level, as well as the exposure to claim losses by the selections made. Tier I parameters To enroll in the Tier I plan, choose one of the claim limits and one maximum premium percentage below. (Claim limit) (maximum costs chargeable to a single claim) $200,000 $300,000 $400,000 No claim limit Tier II parameters To enroll in the Tier II plan, choose one of the claim limits below. (Claim limit) (maximum costs chargeable to a single claim) $100,000 $125,000 The Tier II plan only offers a maximum premium of 150 percent. Maximum premium 150 percent 200 percent No If you do not meet the requirements for Tier I, do you wish BWC to consider you for the Tier II plan? Yes Financial statements are attached for consideration. Estimated policy year payroll You must provide the estimated payroll you will report during the policy year for each manual classification assigned to your policy number (attach additional pages as needed). The public employer taxing district policy year is Jan. 1 to Dec. 31. The payroll information below will be used to set the estimated annual premium for the policy year beginning July 1. You must use NCCI manual classification numbers for BWC to consider your application. NCCI manual number Payroll Payroll rounded to the nearest $1,000 NCCI manual number Payroll NCCI manual number Payroll Retrospective-Rating Application ­ Statement of agreement: I have been authorized to sign and execute this application for the retrospective-rating plan on behalf of the company. I have read and understand the retrospective-rating plan rules in their entirety and agree to comply with the terms of the retrospective-rating plan, including payment of the annual claims billings in accordance with the plan and the governing rules. Owner/partner/officer name (type or print) Signature Title Date Note: BWC's employer programs' retrospective-rating unit must review and approve this application before it becomes effective. BWC will provide written notification of application acceptance/rejection and applicable minimum premium percentage following the review. BWC-7523 (Rev. April 1, 2016) For the policy year effective American LegalNet, Inc. www.FormsWorkFlow.com U-21