Application for Deductible Program Instructions ·Completethisapplication. ·An (*) denotes a required field. BWC cannot process incompleteapplications. ·Anofficer,partnerorownermustsignthisapplication. ·Youmaysubmitthecompletedforminoneofthreewayslistedbelow. Online­ www.bwc.ohio.gov Fax ­614-621-1405 Mail ­ ttention:EmployerPrograms A OhioBureauofWorkers'Compensation 30W.SpringSt.,22ndFloor Columbus,OH43215-2256 Youmayonlycombinecertainprogramsinthediscountcalculation.PleasereferencethecompatibilitychartfoundinOhio AdministrativeCode4123-17-74appendixC. Policy information FederalemployeridentificationorBWCpolicynumber* SocialSecuritynumber Legalbusinessname*Tradenameordoingbusinessas Primaryphysicallocation(donotuseP .O.Box)*City*State*ZIPcode* Employer program contact information Contactname*Title EmailPhone* ax F Deductible level (Selectalimitbelow) Minimum premium requirements $500 $1,000 $2,500 $5,000 $10,000 $25,000 $50,000 Additional information required Thedeductiblelevelselectedmaynotexceed None 25percentofanemployer'sannualpremium. Thedeductiblelevelselectedmaynotex- Reviewed or audited financial statements ceed 40 percent of an employer's annual preparedinaccordancewithgenerallyacpremium. ceptedaccountingprinciplesforthethree mostrecentfiscalyears. Thedeductiblelevelselectedmaynotex- Audited financial statements prepared in ceed 40 percent of an employer's annual accordance with generally accepted ac$100,000 $200,000 premium. countingprinciplesforthethreemostrecent fiscalyears. Ifmycompanyisnoteligibleforthedeductiblelevelselected,IwouldlikeBWCtoplacemeatthenexthighestperclaim deductibleamountinwhichmycompanymeetstheeligibilityrequirements. Yes No Annual aggregate stop-loss limit Thisoptionisonlyavailableifadeductiblelevelof$25,000ormoreischosen. heannualaggregatelimitcapsanemployer's T totaldeductibleliabilityfortheprogramyeartothreetimesthedeductibleamount.Selectingthisoptionwillresultina reducedpremiumdiscount.Wouldyouliketoenrollintheprogramwiththeaggregatestop-lossoption? Yes No Deductible amounts of $25,000 or more BWCconsidersyourfinancialstatementstradesecrets;pleasesubmitsuchfinancialstatements/informationmarkedorstampedas "Confidential"or"TradeSecret"andacoverletteridentifyingthefinancialstatements/informationassuch. Owner/partner/officer statement of agreement Insigningbelow,asarepresentativefortheemployer,Icertifytheforegoinginformationisaccurateandagreesubjectto theapprovaloftheforegoingapplicationtocomplywithBWC'sDeductibleProgramrule4123-17-72.IunderstandthatANY fraudulentrepresentationsmadeinassociationwiththeDeductibleProgrammayleadtoremovalfromtheprogram,along withBWCbillingtheemployerforpreviousdiscountsassociatedwiththeprogramand/orlegalaction. BWCmayalsoconsidermysignaturebelowasauthorizationtoobtaincreditinformationtodetermineprogrameligibility.I understandthatanycreditinformationobtainedwillbeforofficialBWCuseonlyandwillbekeptconfidential. Owner/partner;officername* Signature* Title* Date* X BWC-7654(Rev.Oct.2,2014) U-148 American LegalNet, Inc. www.FormsWorkFlow.com