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Application For Ohio Workers Compensation Coverage Form. This is a Ohio form and can be use in Employers Workers Comp.
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Tags: Application For Ohio Workers Compensation Coverage, U-3, Ohio Workers Comp, Employers
Application for
Ohio Workers’ Compensation Coverage
Have questions? Need assistance? BWC is here to help!
Call 1-800-OHIOBWC, 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 Web site at ohiobwc.com
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 for Ohio employers and their employees (i.e., employees
whose contracts of hire have been consummated within the borders of Ohio,
whose employment involves activities both within and without the borders
of Ohio and where the supervising office of the employer is located in Ohio),
becomes effective when BWC receives this completed application and the
$10 minimum security deposit. 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 (to qualify must have a single/sole owner 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 owners/officers/ministers
information section of this application.
It’s easy to obtain coverage by following these steps:
1 Apply for coverage online at ohiobwc.com, 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 Detach and mail the completed application with a $10 minimum security
deposit to: Ohio Bureau of Workers’ Compensation
P.O. Box 15698
Columbus, OH 43215-0698
Please make check or money order payable to the Ohio Bureau of Workers’
Compensation, or if you prefer, you may charge the minimum security deposit
to your VISA®, MasterCard® or American Express®.
What happens next?
Once BWC receives your application for
coverage you will receive:
• A new employer kit explaining your
rights and responsibilities, and
cost-saving tips for your business.
The kit includes: an MCO Selection
Guide with instructions on how to
select a managed care organization
to medically manage your company’s
workers’ compensation claims;
Certificate of Premium Payment,
including the effective date of
coverage, which is the day BWC
receives your signed application and
$10 deposit; and your seven-digit
identification number called a BWC
policy number. Please use it whenever
you contact BWC about your policy.
Remove the Certificate of Premium
Payment and post it as proof of
coverage;
• An invoice for the difference between
the $10 minimum security deposit
and the additional security deposit
you owe. The security deposit is
30 percent of your estimated eight
months’ premium up to a maximum of
$1,000. Your security deposit will not
be applied to future premium.
Coverage is not in effect until BWC receives the completed application and the $10 minimum security deposit.
BWC is unable to process incomplete applications.
U-3
BWC-7503 – Instructions – Revised 4/12/2007
Instruction page 1 of 4
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Completing the Application for Ohio Workers’ Compensation Coverage
General information – completed by all employer types
Ohio law requires employers to obtain workers’ compensation coverage for their employees from the first date of hire. Indicate the date you first
hired one or more employees in Ohio or the date you estimate you will hire one or more employees in Ohio. If you do not provide this information,
BWC may bill you for two years of prior-to-coverage premium.
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, or one of the home owners or partners.
BWC uses your primary physical Ohio location to assign one customer service office for all your risk-management services. Please provide
the address for your primary Ohio location best capable of handling and resolving your risk-management issues or an out of state location if
you have no physical Ohio location.
Business entity information
Select the one business entity type that applies to your company. For workers’ compensation purposes, there are four possible business entity
types that apply to a corporation (i.e., limited liability company acting as a corporation, corporation, individual incorporated as a corporation
with no employees and family farm corporation). Select the business entity type that best describes your corporate structure.
Domestic household 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 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 an eight-month payroll estimate so BWC may calculate your premium security deposit. If
you are hiring a contractor to perform these services, you may want to verify he or she has active workers’ compensation coverage.
Sole proprietors and partners (including limited liability companies acting as a sole proprietor or partnership): Sole proprietors and partners
are exempt from workers’ compensation coverage. However, you are required to cover your employees. If you qualify for elective coverage, you
can elect coverage by selecting Yes in the elective coverage section and owners/officers/ministers information section of this application.
Limited liability companies: These companies can elect to be treated as a corporation, sole proprietorship or partnership for income tax
purposes. Because of this, owners of a limited liability company can be treated differently depending upon the form of entity they elect for income
tax purposes. If electing to be treated as a sole proprietorship or partnership, coverage is elective for the owners. If electing to be treated as
a corporation, coverage for the owners is not elective except for an individual incorporated as a corporation. Please check the appropriate
limited liability company box advising whether you are acting as sole proprietor, partnership or a corporation.
Corporations: Corporate officer reportable wages are subject to a minimum and maximum, which is based on the statewide average weekly
wage (SAWW) calculated annually by the Ohio Department of Job and Family Services. The minimum payroll reporting limit will be 50 percent
of the SAWW and the maximum payroll reporting limit will be 150 percent of the SAWW. The minimum reportable payroll applies only to active
executive officers of the corporation (i.e., officers engaged in the decision making and the day to day operation of the corporation). Officers of
a corporation who earn between the minimum and maximum will report their actual W-2 wages. For S-corporations, officers must report wages
for services they perform. This may include W-2 wages as well as all or part of ordinary income from Schedule K-1 up to the maximum.
Note: Visit BWC’s Web site (choose: Ohio Employers; Payroll reporting information under Financial Info heading), or call BWC to obtain the
minimum and maximum payroll reporting requirement amounts applicable for each payroll reporting period.
Individuals incorporated as a corporation (with no employees): To qualify for this business entity type you must have a single/sole owner with
no employees. The single/sole owner with no employees can elect coverage by selecting Yes in the elective coverage section and owners/
officers/ministers information section of this application. Corporations having more than one owner or a single/sole owner with employees are
by law required to have workers’ compensation coverage for all personnel associated with the corporation, including all corporate officers.
Family farm corporation: These officers are exempt from workers’ compensation coverage. However, you must cover their employees. These
family farm corporate officers can elect coverage by selecting Yes in the elective coverage section and owners/officers/ministers information
section of this application. To qualify as a family farm corporation, you must meet the following criteria:
• The family farm must be founded for the purpose of farming animal or plant products intended for consumption by human beings or animals
(excluding nurseries and flower production enterprises);
• A majority of the shareholders must be related within the fourth degree of kinship (siblings, parents, grandparents, aunts, uncles, great aunts,
great uncles or first cousins) or be the spouse of such persons;
• No shareholder may be a corporation;
• At least one of the related persons within the corporation must reside on or actively operate the farm.
Retain for your records
Instruction page 2 of 4
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Business purchase/associated policy information (does not apply to domestic household employees)
You are required to disclose information regarding the purchase of a business or policies associated with the business applying for coverage.
This information assists BWC with accurately processing and rating your application for Ohio workers’ compensation coverage.
Effective July 27, 2006, for all successions taking place on or after Sept. 1, 2006, in situations where a successor takes over the entire operation,
any and all existing and future liabilities or credits will transfer to the successor in addition to the experience. In such cases, it will be the
successor’s responsibility to notify BWC of the succession. When you acquire or purchase a business, you must apply for coverage if you do
not already have an Ohio workers’ compensation policy and you must submit a completed Notification of Acquisition/Merger or Purchase/Sale
(U-118).
Elective coverage (does not apply to domestic household employees)
Coverage on the owners or officers of a corporation and a limited liability company acting as a corporation (except for individuals incorporated as a corporation) is not voluntary. However, coverage on certain owners or ministers is elective. The categories of individuals that
qualify for elective coverage are listed below.
• Sole proprietor
• Partnership
• Limited liability company acting as a sole proprietor
• Limited liability company acting as a partnership
• Family farm corporate officers
• Ordained or associate ministers of religious organizations in the exercise of their ministries
• Individual incorporated as a corporation (with no employees)
If you qualify for elective coverage, you can elect coverage by selecting Yes in the Elective coverage section and owners/officers/ministers
information section of this application. Once the policy has been established, you will need to complete the Application for Elective Coverage
(U-3S) to add additional qualifying owners or ministers. Remember, if you choose not to cover yourself and you are injured at work, BWC will
not provide coverage, and other insurance may not cover your work-related disability or medical bills.
Specific payroll reporting requirements associated with elective coverage are listed below.
Sole proprietors and partners (including limited liability companies acting as a sole proprietor or partnership): For all individuals electing
coverage, the reportable wages are subject to a minimum and maximum, which is based on the SAWW calculated annually by the Ohio
Department of Job and Family Services. The minimum payroll reporting limit will be 50 percent of the SAWW and the maximum payroll reporting
limit will be 150 percent of the SAWW. Individuals who earn between the minimum and maximum will report their actual net incomes based
on their form 1040, Schedule C for sole proprietors, or form 1065 Schedule K-1 for partnerships, inclusive of any draws.
Officers of a family farm corporation: For corporate officers of a family farm electing coverage, the reportable wages are subject to a minimum
and maximum, which is based on the SAWW calculated annually by the Ohio Department of Job and Family Services. The minimum payroll
reporting limit will be 50 percent of the SAWW and the maximum payroll reporting limit will be 150 percent of the SAWW. Officers of a corporation
who earn between the minimum and maximum will report their actual W-2 wages. For S-corporations, officers must report wages for services
they perform. This may include W-2 wages as well as all or part of ordinary income from Schedule K-1 up to the maximum.
Religious organizations: Ohio law requires religious organizations to cover their paid employees. However, ordained ministers and associate
ministers are not considered employees for the purpose of workers’ compensation. When a minister is covered under the religious organization’s
policy, actual earnings are reportable and are not subject to the minimum and maximum. Ministers not covered under the religious organization’s
policy can complete an application for coverage and elect coverage on themselves as a sole proprietor. Ministers electing coverage as a sole
proprietor are subject to the minimum and maximum reporting requirements as described above.
Individuals incorporated as a corporation (with no employees): For individual corporate officers electing coverage, the reportable wages are
subject to a minimum and maximum, which is based on the SAWW calculated annually by the Ohio Department of Job and Family Services.
The minimum payroll reporting limit will be 50 percent of the SAWW and the maximum payroll reporting limit will be 150 percent of the SAWW.
Officers of a corporation who earn between the minimum and maximum will report their actual W-2 wages. For S-corporations, officers must
report wages for services they perform. This may include W-2 wages as well as all or part of ordinary income from Schedule K-1 up to the
maximum.
Note: Visit BWC’s Web site (choose: Ohio Employers; Payroll reporting information under Financial Info heading), or call BWC to obtain the
minimum and maximum payroll reporting requirement amounts applicable for each payroll reporting period.
Retain for your records
Instruction page 3 of 4
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Owners/officers/ministers information (does not apply to domestic household employers)
You must provide name, home address, Social Security number and title (attach additional sheets, if necessary). Additionally, individuals that qualify
for elective coverage must indicate whether or not they wish to elect coverage for themselves.
Religious organizations must list the ordained or associate ministers they elect to cover under the religious organization’s policy in this section.
Operations description (does not apply to domestic household employers)
A complete description of your business is necessary to classify your operations. If you supply inadequate information, BWC could misclassify
your policy. To prevent this from occurring, BWC asks that you supply in-depth information regarding your processes, the equipment used and
any final product you may produce.
Payroll by operation type (does not apply to domestic household employers)
Provide the estimated eight-month payroll for each operation conducted by your employees as well as the number of employees you have
under each operation.
All applications require a signature. Please be sure to complete this area.
Coverage is not in effect until BWC receives the completed application and the $10 minimum security deposit. BWC is unable to process
incomplete applications.
Retain for your records
Instruction page 4 of 4
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Application for
Ohio Workers’ Compensation Coverage
Have questions? Need assistance? BWC is here to help!
Call 1-800-OHIOBWC, 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 Web site at ohiobwc.com
BWC is unable to process incomplete applications. (*Required)
General information - completed by all employer types
*Legal business name or homeowner
Trade name or doing business as name
*Date one or more employees hired in Ohio
*Federal employer identification number or Social Security number
*Primary physical (Ohio) location: If no Ohio location, provide your out-of-state location (Attach additional locations, if applicable)
Street (Do not use P.O. box)
City
State
ZIP code
*Location phone
E-mail address
Location fax number
Web site
*Contact name
*Contact phone
Mailing address: If different from primary physical (Ohio) location
Street
Contact name
City
State
ZIP code
Contact phone
Business entity information
Domestic household (applies to domestic workers employed inside and outside your private residence)
Check the type of services your domestic household employees will perform within your residence.
Domestic inside and/or outside yard/ground maintenance
Home improvement/Maintenance
Construction (new/addition/roofing) on or in your home.
Eight-month payroll estimate _______________
STOP! You have completed the application for domestic coverage. Please sign the application, and return this form to BWC along with your
$10 minimum security deposit.
*Please check the one business entity type below that applies to you.
Sole proprietor
Limited liability company acting as a sole proprietor
Partnership
Limited liability company acting as a partnership
Limited partnership
Limited liability company acting as a corporation
Incorporation date
Charter number
Corporation
Individual incorporated as a corporation
Family farm corporation
State where incorporated
Business purchase/Associated policy information
*Have there been other Ohio workers’ compensation
*Have any of the principals involved in this operation had
policies associated with this operation?
workers’ compensation coverage?
Yes
No
Yes
No
If yes to either of the above questions, list the policy number(s) and/or business legal name below, use additional sheets if necessary.
List policy(s)#
*Did you acquire/purchase this
business?
Yes
No
Name
*Previous owner’s name and BWC policy number
*Do you have a purchase agreement?
Yes
No
If yes, BWC may request a copy of the agreement.
U-3
BWC-7503 – Form – Revised 4/11/2007
*Date you acquired/purchased
business
*Did you acquire/purchase
or
Part of business?
All
*If you acquired or purchased a business, you must also complete
the Notification of Acquisition/Merger or Purchase/Sale form (U-118).
Application Page 1 of 4
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Elective coverage
See additional details in the business entity information and elective coverage sections for completing the application, which describe the
reporting requirements for elective coverage.
Coverage on the owners or officers of a corporation and a limited liability company acting as a corporation (except for individuals incorporated
as a corporation with no employees) is not voluntary.
However, coverage on certain owners or ministers is voluntary. Listed below are the categories of individuals that qualify for elective coverage.
• Sole proprietor
• Partnership
• Limited liability company acting as a sole proprietor
• Limited liability company acting as a partnership
• Family farm corporate officers
• Ordained or associate minister of a religious organization
• Individual incorporated as a corporation (with no employees)
*If someone at your company meets the qualifications for elective coverage, do you wish to elect coverage?
Yes Important – Indicate which individuals you wish to cover in the owners/officers/ministers information section of this application.
By electing coverage you are acknowledging your agreement to the minimum payroll reporting outlined in the instruction sheet.
No I understand I elected to NOT cover any individuals at my company that qualify for elective coverage. (Remember, if you choose not to cover yourself
and you are injured at work, BWC will not provide coverage, and other insurance may not cover your work-related disability or medical bills.)
*Initials: ____________
Owners/officers/ministers information – You must list all owners/officers, and any ministers you elect to cover under
the religious organization’s policy. (Attach additional sheets, if necessary.)
*Name #1 (last, first, middle)
*% Ownership
*Home address (street or PO Box)
*City
*State
*Social Security number
*ZIP code
*Title
*For individuals that qualify, do you wish to elect coverage?
Yes I do wish to elect coverage for myself.
No I understand that BWC will not pay benefits for my work-related injury if I do not elect coverage.
*Name #2 (last, first, middle)
*% Ownership
*Home address (street or PO Box)
*City
*State
*Social Security number
*ZIP code
*Title
*For individuals that qualify, do you wish to elect coverage?
Yes I do wish to elect coverage for myself.
No I understand that BWC will not pay benefits for my work-related injury if I do not elect coverage.
*Name #3 (last, first, middle)
*% Ownership
*Home address (street or PO Box)
*City
*State
*Social Security number
*ZIP code
*Title
*For individuals that qualify, do you wish to elect coverage?
Yes I do wish to elect coverage for myself.
No I understand that BWC will not pay benefits for my work-related injury if I do not elect coverage.
*Total ownership %
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Operations description
*Check all types that apply to your Ohio operations: (note: applicable to your Ohio operation only)
Agriculture
Crop
Livestock
Dairy
Vegetable
Poultry
Orchard
Extraction
Manufacturing
Mining
Transportation
Utility
General contractor
Apartments/condos
Type of material used
Other (describe)
Owned goods
Gen. Freight
Distance
Gas
Phone
Quarry
Other
Subcontractor
Permanent yard operations
Residential three stories and under
Commercial, industrial and dwellings more than three stories
Interior trim/cabinets
Steel
Concrete
Wood
Masonry
Ceramic
Paint
Non-owned goods
Ground
Parcel
People
Local 200 miles or less
Oil
Cable
Electric Water
Service/drop line
Air carrier Water transport
Appliance Furniture
More than 200 miles
Sewer
Trunk line
Wholesale: Sales_____%
Retail: Sales_____%
Packaging
Repair
Principal products sold
Other
Coffee or tea house (no cooking)
Beverages_____% of total sales
Service
Restaurant – fast food
Restaurant – wait service (not counter)
Delivery
Alcohol ____% of receipts compared to total sales
Warehousing for others
Religious organization
Residential house cleaning
Vacant residential cleaning
Domestic employees working in your home
High risk
Explosive
commercial/service
Office work/
miscellaneous
Medical office
Temp. agency
Police/security
Interstate carrier
Oil
Gas
Other
Commercial
(merchandising)
Other
All types, including assembly or shop repair
Construction
Oil or gas
Berry/vineyard
Fire/EMS Atomic/nuclear
Drivers/delivery
Food _____% of total sales
Commercial cleaning
Other
Other
Attorney
Real estate agent Property management
Consulting (Please explain under operation description.
Professional employer organization (PEO)
Other
*Describe your primary services or products, including your methods of operations. Include raw and semi-finished materials used (attach additional
documentation, if necessary). Note: It is important for you to provide as much information as possible for BWC to properly determine your correct
classification.
*Describe machinery, equipment and tools (attach additional documentation, if necessary).
*If you do not have a primary physical Ohio location, provide an explanation for not having an Ohio location and/or reason you are applying for Ohio coverage:
Are you an out-of-state (non Ohio-based) employer temporarily working within Ohio? Yes If yes, In Ohio 90 days or less?
In Ohio more than 90 days?
No
Are your employees covered under another workers’ compensation policy issued for a state other than Ohio? Yes If yes, provide the following information
No
Insurer name
Policy number
Was the contract of hire for your employees entered into (consummated): Select one Exclusively in Ohio Exclusively in a state other than Ohio
Combination of Ohio and in a state other than Ohio
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Payroll by operation type
*For each operation type, estimate *For each operation type, estimate
total number of employees.
total payroll for next eight months.
*List all types of operations that apply (attach additional sheets if
necessary).
The following are in addition to the above:
Clerical Office personnel (no duties outside of the office, no counter service);
Telecommuter (clerical employees working from residence);
Traveling salespeople (no handling, servicing or delivery);
Drivers (truck or delivery);
Sole proprietors, partners or ministers (if self-coverage is elected);
Elective coverage (only if self-coverage is elected).
Certification – signature required
Name (please print)
By my signature, I certify I have the authority to execute this application, and that the facts set forth on this application are true and correct to the best of my knowledge and belief. I am
aware that any person who does not secure or maintain workers’ compensation coverage and pay all appropriate premiums in accordance with Ohio laws, or misrepresents, conceals
facts, or makes false statements to obtain coverage may be subject to civil, criminal and/or administrative penalties.
*Employer signature
*Date
Warning: Insurance is not in effect until BWC receives the application and the $10 security deposit.
BWC will bill the balance of the security deposit.
BWC is unable to process incomplete applications.
You also may pay by check or money order.
Mail completed form and
$10 security deposit to:
Ohio Bureau of Workers’ Compensation
P.O. Box 15698
Columbus, OH 43215-0698
Credit card payment information
VISA®
MasterCard®
American Express®
Credit card account no.
Amount paid
Expiration date
Signature
Date
Print name as it appears on credit card.
BWC USE ONLY
Policy number
Application number
Effective date
Payment type
Cash
Check
Payment amount Date received Initials
Charge
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