One Time Lump Sum Settlement (LSS) Exclusion Program For Public Employer State Agencies
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One Time Lump Sum Settlement (LSS) Exclusion Program For Public Employer State Agencies Form. This is a Ohio form and can be use in Employers Workers Comp.
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Tags: One Time Lump Sum Settlement (LSS) Exclusion Program For Public Employer State Agencies, BWC-7650, Ohio Workers Comp, Employers
One-Time Lump Sum Settlement (LSS)
Exclusion Program for
Public Employer State Agencies
INSTRUCTIONS:
• This One-Time LSS Exclusion Program (One-Time Exclusion) is available to those public employer state (PES) agencies
that are not currently participating in a settlement payment program.
• State agencies may NOT participate in the One-Time Exclusion while also participating in the LSS Direct Reimbursement
Payment and Rating Program (LSS Program).
• Eligible state agencies that wish to choose both LSS programs must first enroll in the One-Time Exclusion and must
conclude settlements on identified claims by June 30, 2006.
• 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.
• Applications must be submitted by July 1.
• On page 2 of this application form, the state agency must submit a comprehensive list of claims that the agency plans to
settle by June 30, 2006, and wishes to have the settlement payments excluded from the rating process.
• 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
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/
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.
Printed or typed name of executive staff signing this application
Signature of designated executive staff
Title of person signing this application
Date
BWC-7650 (Rev 6/2/04) PC
U-144
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
Injured worker last name, first name
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Injured worker SSN
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BWC-7650 (Rev 6/2/04) PC
U-144
American LegalNet, Inc.
www.USCourtForms.com
