APPLICATION FOR HOUSEHOLD DOMESTIC EMPLOYEES ONLY BWC USE ONLY Date application mailed MANUALS Effective date Risk number TO BE FILLED OUT BY EMPLOYER A household which pays a domestic worker $160.00 or more in cash, in any calendar quarter must carry Workers' Compensation coverage for that employee. Other employees who earn less than $160.00 per calendar quarter may be included in this coverage, at your option, by including them in the total number of employees and including their wages in the estimated payroll below. Remit check payable to Bureau of Workers' Compensation in the amount of $10.00 (minimum) for advance premium deposit and forward to: 30 West Spring Street, Columbus, Ohio 43215-2256. WARNING: NO INSURANCE IS IN EFFECT UNTIL APPLICATION AND MINIMUM $10.00 SECURITY DEPOSIT ARE RECEIVED. EMPLOYER name (first, middle, last) Social Security number SPOUSE (if applicable) name (first, middle, last) Social Security number ADDRESS (number and street) Telephone number City State ( County 9-digit ZIP Code ) Employer's Signature(s) Number of employees Estimated total payroll for next eight months Date Do you currently have a Workers' Compensation Account Yes No If yes, please provide Risk Number NATURE OF WORK PERFORMED BY THE ABOVE EMPLOYEE(S) For Departmental Use Only – DO NOT WRITE IN THIS BOX Using the information contained in the foregoing application as a basis, the Industrial Commission has assigned the following classification: MANUAL DESCRIPTION ESTIMATE RATE BASIC RATE TOTAL DUE TOTAL PAID BALANCE DUE PREMIUM v v v THE INDUSTRIAL COMMISSION OF OHIO BUREAU OF WORKERS' COMPENSATION EMP. Payment Received by Date___________Hour_____________Amount $___________Check___________M.O.___________Cash__________ BWC-7504 (Rev. 11/17/95) U-3-B 2000 © American LegalNet, Inc.