Lump Sum Settlement (LSS) Direct Reimbursement Payment and Rating Program for Public Employer State Agencies INSTRUCTIONS: • This LSS Program is available to only those public employer state agencies that are not currently participating in a settlement payment program. • State agencies may choose to participate in the LSS Program for any program year including immediately following conclusion of participation in the One-Time LSS Exclusion Program. • The LSS Program requires a three-year commitment and is automatically renewable unless BWC is notified otherwise. • Applications must be submitted prior to the first day of January immediately preceding the policy year (beginning July 1) in which the agency wishes to participate. • Completed form should be sent to BWC Actuarial Section, L-25, 30 W. Spring St., Columbus OH 43215 A letter of acknowledgement of receipt of this application will be sent to the state agency submitting this form. Policy number Agency name Address City State 9-digit ZIP code Office telephone number Fax number ( County ( ) E-mail address ) Effective date of participation I affirm that the information provided on this form is accurate to the best of my knowledge. I further affirm that I have the authority to sign this application form as a designated executive representative of my agency and that by my signature below I commit my agency to follow all rules and procedures relative to this program. Name of signatory Signature of designated executive staff Title of person signing Date BWC-7651 (Rev 10/27/2005) PC U-145 American LegalNet, Inc. www.FormsWorkflow.com