Application for Ohio Workers' Compensation Coverage Have question? Need assistance? BWC is here to help! Call 1-800-644-6292, and listen to the options to reach a customer service representative. You can dial the number nationwide, and in Canada and Mexico from 7:30 a.m. to 5:30 p.m. EST. Remember, you can access information and request services by visiting BWC's website at www.bwc.ohio.gov. Workers' compensation coverage protects you and your employees in the event of a work-related injury, disease or death. In Ohio, all employers with one or more employees must carry workers' compensation coverage. It's the law. Coverage becomes effective when BWC receives this completed application and the $120 non-refundable application fee and shall be contingent on the timely receipt of the first installment payment. Independent contractors and subcontractors also must obtain coverage for their employees. BWC considers officers of a corporation employees for the purposes of workers' compensation; except for an individual incorporated as a corporation with no employees. However, if you are self-employed, a partner in a business, an officer of a family farm corporation or an individual incorporated as a corporation, you are not automatically covered. You may elect coverage for yourself by selecting Yes in the elective coverage section and the owners/officers/ ministers information section of this application. Note: Even if you do not elect coverage for yourself you must have coverage for any employees you hire. What happens next? Once BWC processes your application, you will receive: · A policy invoice for your first installment. BWC determined your estimated annual premium from the 12-month estimated payroll you submitted. BWC uses this figure to calculate installments; · A Notice of Estimated Annual Premium, which provides you with pertinent information about your policy.The notice also directs you to the new employer kit, which explains your rights and responsibilities. It also provides cost savings tips for your business. In addition, the kit includes an MCO Selection Guide that contains instructions on how to select a managed care organization (MCO). MCOs manage the medical portion of your company's work er s ' compensation claims; · Certificate of Ohio Work er s ' Compensation Coverage, which includes the effective date of coverage. Coverage is contingent upon timely receipt of your first installment payment. You must post the Certificate of Ohio Workers' Compensation Coverage as proof of coverage. It's easy to obtain coverage by following these steps. Apply for coverage online at www.bwc.ohio.gov, or complete all fields on this application for coverage. 2. Provide as many details as possible. When describing the nature of the business, include the type of work performed and the equipment used. 3. Sign and date the application. It's not valid without a signature. 4. Mail the completed application with the $120 non-refundable application fee to: Ohio Bureau of Workers' Compensation P Box 15698 .O. Columbus, OH 43215-0698 Please make check or money order payable to the Ohio Bureau of Workers' Compensation. General information 1. Ohio law requires employers to obtain workers' compensation coverage for their employees from the first date of hire. Indicate the date your employees first earned wages in Ohio or the date you estimate your employees will first earn wages in Ohio. If you do not provide this information, you may be assessed a penalty for non-covered periods where coverage should have been obtained. Be sure to supply your federal employer identification number (FEIN). You can obtain a FEIN number by calling the Internal Revenue Service. If you have applied for a FEIN, but have not received one, write "applied for" in the appropriate box, and you may supply it at a later date. Domestic household employers, sole proprietors and partnerships who do not need a FEIN should supply a Social Security number of the sole proprietor, one of the home owners or partners. Address information BWC uses your primary physical Ohio location to assign one customer service office for all your policy services. Please provide the address for your primary Ohio location best capable of handling and resolving your policy issues or an out of state location if you have no physical Ohio location. BWC will send all employer related correspondence including your policy invoice to the mailing address. If no mailing address is provided, BWC will use the primary physical Ohio location for all employer notifications. Coverage is not in effect until BWC receives the completed application and the $120 non-refundable application fee. In addition, coverage should be contingent on the timely receipt of the first installment payment. BWC cannot process incomplete applications. BWC-7503 (Rev. Nov. 20, 2015) U-3 Instruction page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Additional Ohio locations This section is used for additional Ohio locations that may be covered under this policy. Please provide a brief description of operation for each location. Business information Please provide general business information for your primary location. Business contact information Provide specific individual(s) information that will allow BWC to make direct contact with those handling your workers' compensation matters. Domestic household coverage Coverage applies to full or part-time domestic workers employed inside or outside your private residence and includes private chauffeurs. Domestic household employers who pay workers $160 or more in a calendar quarter must have workers' compensation insurance. Normally these workers provide domestic services such as gardening, housekeeping, babysitting, etc. However, you should include workers you hire as employees to provide home improvement for construction type activities to your residence if the worker does not have his or her own business or their own workers' compensation insurance. Please check the appropriate box under Domestic household employer that applies to the type of worker you will hire, and supply a 12-month estimate so BWC may calculate your future installment payments due. If you are hiring a contractor to perform these services, you may want to verify he or she has active workers' compensation coverage. Business entity information Select the one business entity type that applies to your company. For workers' compensation purposes, there are four possible busin