Amended Payroll Report Instructions You must complete this form in its entirety along with a reason for the change. If supplemental coverage applies (sole proprietor, partnership, limited liability company acting as a sole proprietor/partnership, family farm corporate officer, or ministers), you must report the payroll under the correct National Council on Compensation Insurance classification and manual type code (SN). Policy number Legal business name Trading name or doing business as name Mailing address E-mail address Telephone number ( City State ) ZIP code Payroll period from Manual through NCCI manual classification Type code Description Original reported payroll Actual payroll $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Reason for change Certification I hereby certify the amended payroll reported herein is correct as to the classification and amount for the period stated. I understand that misrepresentation of payroll for premium purposes could lead to a penalty of 10 times the amount of the premium underreported, as provided by Section 4123.25 of the Ohio Revised Code. Signature and title (must be signed by owner, partner or officer) Date BWC-7578 (Rev. 1/25/2011) RPS-Amend P/R American LegalNet, Inc. www.FormsWorkFlow.com