Apprenticeship Elective Coverage Contract This contract, by and am ong (Organizat ion Nam e, St reet Address, Cit y, St at e, ZIP code, policy num ber) and the Adm inistrator of the Ohio Bureau of Workers' Com pensation, entered into pursuant to the authority contained in Section 4123.039 of the Ohio Revised Code, in consideration of m utual prom ises, agreem ents and covenants herein contained. 1. Definit ions The definitions below , w hen used w ith an initial capital letter or letters, shall apply throughout this contract. 1.1 Em ployer m eans Organizat ion Nam e, St reet Address, Cit y, St at e, ZIP code, policy num ber. 1.2 Adm inistrator m eans the Adm inistrator of the Ohio Bureau of Workers' Com pensation. 1.3 Bureau m eans the Ohio Bureau of Workers' Com pensation, an agency of the State of Ohio government. 1.4 Code m eans the Ohio Revised Code, as am ended from tim e to time. 1.5 Apprentices m ean apprentices as defined under Section 4139.01 of the Code, and pre-apprentices, entry-level trainees and journeym an trainees as defined collectively in Section 4123.038 of the Code. 1.6 Adm inistrative Code m eans the Ohio Adm inistrative Code, as amended from time to tim e. 1.7 Supplem ental Instruction m eans classroom instruction, w orkshop training, or on-the-job training. 1.8 IRS m eans the Internal Revenue Service, an agency of the United States government. 1.9 ODJFS m eans the Ohio Departm ent of Job and Fam ily Services, an agency of the State of Ohio government. 1.10 FUTA m eans Federal Unem ploym ent Tax Act, as am ended from tim e to time. 1.11 NCCI m eans National Council on Com pensation Insurance, Inc. 1.12 DWRF m eans Disabled Workers' Relief Fund, as defined in Section 4123.412 of the Code. 1.13 Prem ium Security Deposit m eans prem ium security deposit as defined in Section 4123.32 of the Code. 1.14 Adm inistrative Assessm ent m eans the adm inistrative cost assessm ent pursuant to Section 4123.342 of the Code and applicable Adm inistrative Code and Bureau policies. 1.15 SAWW means statew ide average w eekly w age, as defined in Section 4123.62(C) of the Code. Em ployer Is a Sponsoring Organizat ion or Joint Com m itt ee Em ployer acknow ledges being a sponsoring organization or joint com m ittee offering, conducting, supervising or giving to Apprentices supplem ental instruction. Em ployer Desires Volunt arily t o Secure Coverage for Apprent ices Em ployer recognizes w orkers' com pensation coverage of its Apprentices is not m andatory under Ohio law unless Apprentices are em ployees of Em ployer as defined under Section 4123.01 of the Code. 3.1 Em ployer elects to secure w orkers' com pensation coverage under Ohio law for its Apprentices for supplem ental instruction offered by Em ployer. 3.2 Em ployer acknow ledges this Contract does not supersede or replace any other obligations to m aintain w orkers' com pensation coverage for its em ployees under Chapter 4123 of the Code. Record Keeping Requirem ent s by Em ployer Em ployer agrees to m aintain verifiable, accurate and current records regarding Apprentices covered under this Contract. 4.1 Nam es, Addresses and Last Four Social Securit y Num bers of Apprent ices ­ Em ployer agrees to maintain at all tim es during the life of the contract a verifiable, accurate, and current list of the nam es, addresses and last four digits of the Social Security num ber of Apprentices engaged in Supplemental Instruction offered, conducted, supervised or given by the Em ployer. 4.2 Rem unerat ion t o Apprent ices ­ Em ployer agrees to docum ent and report all rem uneration to Apprentices to the Bureau, w ith rem uneration defined in accordance w ith IRS, FUTA, ODJFS and Bureau policies on w hich prem ium , DWRF Assessm ent, Adm inistrative Assessm ent, and Premium Security Deposit ow ed under this Contract are to be calculated. 4.2.1 Rem unerat ion t o be Segregat ed by M anual Classificat ion ­ Em ployer recognizes prem ium s levied and collected by Adm inistrator under this Contract are dependent upon an accurate reporting of rem uneration received by Apprentices according to the m anual classifications developed by NCCI. Em ployer agrees to record rem uneration to Apprentices according to NCCI's m anual classifications for each Apprentice in accordance w ith Section 4.2.2 below . 4.2.2 NCCI M anual Classificat ions ­ Em ployer agrees that it w ill use NCCI classifications in reporting as follow s. Sect ion 4.2.2.1 Inst ruct ors and Assist ant Inst ruct ors ­ Report rem uneration to instructors and assistant instructors providing Apprentices supplem ental instruction under NCCI m anual classification 8868, College: Professional Em ployees & Clerical. Sect ion 4.2.2.2 Apprent ices in Classroom Inst ruct ion or Workshop Inst ruct ion Where No Physical Act ivit y 2. 3. 4. BWC-7584 (5/18/2011) PC U-80 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 5. 6. Is Perform ed ­ Report rem uneration to Apprentices w ho receive only classroom instruction or w orkshop instruction w here Apprentices do not participate physically or in hands on environm ent under NCCI m anual classification 9101, College: All Other Em ployees. Sect ion 4.2.2.3 Apprent ices in On-t he-Job Training or Workshop Training Where Physical Act ivit y is Perform ed ­ Categorize rem uneration to Apprentices w ho engage in on-the-job training or in w orkshop instruction w here Apprentices participate physically or in a hands on environm ent under NCCI's m anual classifications based on Apprentices docum ented duties. Sect ion 4.2.2.4 Apprent ices Who Receive Classroom Inst ruct ion and Perform Physical Act ivit y ­ Categorize rem uneration to Apprentices w ho receive Supplem ental Instruction under Sections 4.2.2.2 and Section 4.2.2.3 under NCCI's m anual classifications on a prorated basis. Adm inistrator and Em ployer acknow ledge this is an exception to NCCI standards. 4.2.3 Num ber of Apprent ices ­ Em ployer recognizes prem ium s levied and collected by Adm inistrator under this contract are dependent upon an accurate reporting of the num ber of Apprentices of Em ployer covered under this Contract. Em ployer states at the tim e of entering into this Contract, _______(Num ber) Apprentices are, or reasonably believes by ______________, _____, (Dat e) are engaged in Supplem ental Instruction w ith Em ployer, all pursuing the know ledge and skills in the occupational field of__________________. When required to report an updated number of Apprentices b