MCO Selection Form Employer policy number: Company name: Doing business as: Contact name: Number of employees: Phone number with extension: Fax number: County of operation: Mailing address: City: Name of MCO selected: MCO number: Complete this form, then mail or fax it to BWC using the address or fax number found below. Remember to keep a copy for your records. (Use the policy number found on your certificate of coverage.) ext. (Use the two-digit number from the County codes on page 4 of this guide.) State: ZIP code: (Use the five-digit number from the Alphabetical MCO list on page 4 of this guide.) Employer's signature: Employer name (print): Employer title: Date: M M D D Y Y Y Y Employer's right to select An employer may select any MCO that meets its individual business needs. The MCO selection is solely the employer's choice. Mail or fax form to: Ohio Bureau of Workers' Compensation Attn: Open Enrollment 30 W. Spring St., 22nd Floor Columbus, OH 43215-2256 Fax: 614-719-5313 5 American LegalNet, Inc. www.FormsWorkFlow.com