One-Time Lump Sum Settlement Exclusion Program for State Agencies QUARTERLY REPORTING FORM INSTRUCTIONS FOR QUARTERLY REPORT FILING: • Public employer state (PES) agencies participating in the One-Time Lump Sum Settlement (LSS) Exclusion Program (One-Time Exclusion) are required to submit a quarterly report to BWC of claims that were settled and related settlement payments that should be excluded from the rate calculations. • Claims that have not been settled by June 30, 2006 will be included in rate calculations. • The One-Time Exclusion is limited to two years and will then expire. Eligible state agencies may then choose to enroll in the LSS Program at a later date. • The deadline for the One-Time Exclusion is June 30, 2006 meaning that the payment of the settlement for any claims selected must be made on or before June 30, 2006. • Any LSS payments after June 30, 2006 will be used in rate calculations and will not be billed to the PES agency for reimbursement unless the agency is participating in the LSS Program following conclusion of participation in the One-Time Exclusion. • Filing of the Quarterly Reporting Form must be made within 15 days of the end of the quarter, or the PES agency may be considered ineligible to continue with the One-Time Exclusion. Quarterly Reporting Forms must be filed even if no settlements have been made that are applicable to this program • Failure to timely pay any billing incurred from participating in the One-Time Exclusion will cause the PES agency to be removed and the LSS payments will be included in the rate calculations. • Return completed form to BWC Employer Programs, L-22, 30 W. Spring St. Columbus, OH 43215. Agency name Policy number Address City State County Office telephone number ( ) Fax number ( ) E-mail address 9-digit ZIP code - Effective date of participation / / Billing Information (fill out only those portions that differ from the demographic information requested above) Agency name Policy number Address City State County Office telephone number ( ) Fax number ( ) E-mail address 9-digit ZIP code - Quarter end date / / I affirm that the settlement information provided on this reporting form is accurate to the best of my knowledge. I further affirm that I have the authority to sign this reporting form as a designated executive representative of my agency and that by my signature below I affirm that my agency is follow all rules, procedures and other requirements relative to this program. Printed or typed name of executive staff signing this application Signature of designated executive staff BWC-7649 (Rev 6/2/04) PC U-143 Title of person signing this application Date American LegalNet, Inc. www.USCourtForms.com Claims Information (Claims agency plans to settle and wants settlement payments excluded from rate calculation process) Claim number Injury date last name Injured worker first name Injured worker SSN Settlement Date Amount Medical (M), Indemnity (I) or Full (F) Settlement BWC-7649 (Rev 6/2/04) PC U-143 American LegalNet, Inc. www.USCourtForms.com